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THE DISEASES

THE HEART AND THE AORTA.

THE DISEASES

THE HEART AND THE AORTA.

WILLIAM STOKES,

REGIUS PROFESSOR OF PHYSIC IN THE UNIVERSITY OF DUBLIN;

HONORARY MEMBER OF THE ROYAL MEDICAL SOCIETY OF EDINBURGH, OF THE PATHOLOGICAL AND EPIDEMIOLOGICAL
SOCIETIES OF LONDON, AND OF THE IMPERIAL SOCIETY OF PHYSICIANS OF VIENNA ;

CORRESPONDING MEMBER OF THE MEDICO-CHIRURGICAL SOCIETIES OF BERLIN, LEIPZIG, GHENT, AND SWEDEN,
AND OF THE SOCIETY OF STATE MEDICINE IN THE GRAND DUCHY OF BADEN ;

FOREIGN ASSOCIATE OF THE NORWEGIAN MEDICAL SOCIETY ;

HONORARY MEMBER OP THE NATIONAL INSTITUTE OF PHILADELPHIA.

DUBLIN:

HODGES AND SMITH, GRAFTON-STREET,

BOOKSELLERS TO THE UNIVERSITY.

1854.

[The right of publishing a Translation of this Work is reserved.']

DUBLIN *.

printed at tljc Untbcrsitg press,

. BY M. H. GXU..

STAFF-SURGEON JOHN COLLIS CARTER, M.D.,

I DEDICATE THIS VOLUME,

WITH

TRUE RESPECT,

AND

IN REMEMBRANCE OF OUR LONG, UNFAILING,

AND MUTUAL AFFECTION.

♦

ROBERT WILLIAM SMITH, M.D.,

PROFESSOR OF SURGERY IN THE UNIVERSITY OF DUBLIN, &c.

Sir,

In the composition of this work, while
contending with difficulties inseparable from an attempt
to combine the results of many years of labour, I have
always been consoled by the thought that in dedicating
it to you, I should be enabled to bear testimony not
alone to the value of your contributions to Medical Sci-
ence, but also to the signal benefits which your teaching
and example have conferred upon the School of Sur-
gery in this country.

WILLIAM STOKES.

Dublin, Nov. 13, 1853.

PREFACE.

I desire to state in brief terms the objects and nature of
the following Treatise, which else, while we possess such
works as those of Hope, Williams, Latham, and Walshe,
might appear on the one hand uncalled for, and on the
other insufficient. It seeks to embody the results of my
clinical observations, continued almost unremittingly for
upwards of a quarter of a century. Yet it is not to be
taken as a record of every observation on Diseases of
the Heart which may have been made by me during that
time, but rather as expressing the state of opinion pro-
duced in my own mind by a long experience, even
though I cannot recall many of the facts on which that
opinion is founded. A work of this kind, if its author
has had a sufficient experience, and especially if he has
not sought to gratify his self-love by the advocacy of any
new or peculiar doctrine, — than which there is nothing
more likely to warp the judgment, — must always have a
certain value. It is an attempt to convey to others the
state of his own mind, the conclusions which he thinks
may be safely arrived at, and the doubts and difficulties
which he has been unable to solve or to remove.

I have sought to give to this work an essentially
practical character ; and at the cost of omitting much

PREFACE.

of what is new and interesting, I have made use of
pathological anatomy, and the physical diagnosis founded
upon it, only so far as these subjects bear on the every-
day practice of our profession. The work, then, is not in-
tended as a full treatise on Cardiac Pathology, nor yet on
Physical Diagnosis, but it aims at the rational application
of these branches of knowledge to Practical Medicine.
Such a book ought to be useful, and is perhaps required;
and whether the present attempt be successful or the
contrary, my readers may be assured that few of them
will be more convinced of its imperfections than I am
myself.

Without seeking to undervalue even in the slightest
degree the many admirable works on Cardiac Pathology
and Diagnosis which have been produced in our time,
we cannot but admit that their effect on the mind of the
inexperienced man is often different from that intended
by their authors. His deficiency in clinical knowledge
makes him overlook the great fact of the frequent compli-
cation of disease. He applies to a complicated case rules
of diagnosis in which the isolation of disease is assumed;
and while their apparent simplicity makes him confi-
dent in his powers, their inapplicability to the case in
question leads him into grievous error. The diagnosis
of the combinations of diseases even in so small an
organ as the heart is still to be worked out ; and until
this be done, the rules of physical diagnosis founded on
the presumed isolation of disease must be used with
great caution. I cannot, even at the risk of being charged
with understating the position of physical investigation
at the present day, avoid expressing my opinion that a
too great positiveness marks some of the statements in our
standard works, and that the difficulties of special dia-

PREFACE.

gnosis are still infinitely greater than many might be led
to believe.

In these remarks I do not wish to be considered as
undervaluing the labours of the present advanced school
of Physical Diagnosis. I believe that the object to which
its members are directing their researches is the light
one, and that the application of every true principle of
diagnosis to practice will yet be discovered. I only wish
that, until the laws of this department of Vital Physics
are fully and rigorously determined, no hasty or enthusias-
tic anticipations should be received as positive acquisi-
tions to science ; and as I wish this work to be considered
us a treatise on a certain portion of the Practice of Medi-
cine, and have kept this object steadily before me, I have
made use only of such principles of diagnosis as may be
safely received, and have avoided discussions on what
still remains doubtful. I desire also to enter a protest
against the tendency, still too prevalent in many schools,
which would base the diagnosis of disease in great part,
if not entirely, on the consideration of purely physical
signs, to the exclusion of that important class of pheno-
mena, which, for want of a better name, we are obliged
still to call Vital. For there is nothing more calculated
than this to cause the neglect of that first and greatest
lesson in Medicine, which, while inculcating modesty and
caution in diagnosis, makes us bring every possible light
to bear on the case before us.

As the student, fresh from the schools, and proud of
his supposed superiority in the refinements of diagnosis,
advancesinto the stern realities of practice, he will be taught
greater modesty and a more wholesome caution: he will
find, especially in chronic disease, that important changes
may exist without corresponding physical signs, — that
as disease advances, its original special evidences may dis-

PREFACE.

appear, — that the signs of a recent and trivial affection
at one portion of the heart may altogether obscure or
prevent those of a disease longer in standing and much
more important, — that functional alteration may not only
cause the signs of organic lesion to vary infinitely, but
even to wholly disappear, — that the signs on which he
has formed his opinion to-day may be wanting to-morrow,
— and lastly, that to settle the simple question between
the existence of functional and that of organic disease
will occasionally baffle the powers of even the most en-
lightened and experienced physician.

Yet, even since the times of Corvisart and Laennec
there has been a great advance in our knowledge of car-
diac and arterial disease ; and, in proof of this assertion,
it is only necessary to refer to the many works of a formal
nature, and again to the numerous and equally valuable
class of monographs which have been produced on these
subjects during the last few years.

From unavoidable circumstances, the composition
and printing of this work have been spread over a period
of several years. This, I trust, will be taken as an apo-
logy for my omitting to notice some important addi-
tions to our knowledge, which appeared subsequently
to the printing of the chapters devoted to the considera-
tion of these subjects.

Thus I have been unable to notice the observations of
Virchow on obstruction of the arteries in cases of dis-
ease of the aortic valve, nor the confirmatory researches
of Dr. Kirkes, which have been recently published, nor,
again, those of Dr. M‘Dowel on the diagnosis of dilata-
tion of the heart. The memoir of Dr. Gairdner, with
reference to the relation between simple dilatation of the
heart and the atrophic diseases of the lung, contains much
matter for consideration, and should his views as to the

PREFACE.

X1U

influence of the dilating power of the thorax prove cor-
rect, they will throw a new light on diseases of the heart

and also of the aorta8.

I am indebted to Dr. William Moore, of this city,
not only for his kind and constant assistance during the
progress of this work, but for the translation of that por-
tion of the treatise of Skoda which contains the views of
that author on the sounds of the heart, and for the co-
pious Index with which this volume has been furnished.
I wish, further, to express my grateful acknowledgments
to Professor Smith and to Dr. Lyons, of this city, for
their valuable aid.

» It will be observed that in the measurements of the heart, given in the note at page
257, the left ventricle is represented as being longer in women than in men, while all the
other cardiac dimensions are greater in the male than in the female. This is clearly to
be attributed to an error in the original, as at the five other ages at which Bizot g.ves
the lengths of the left ventricle, the reverse appears to be the case ; and m the paragraph
immediately following the Table he observes, “ that the dimensions of the ventricles in
particular, as well as the general dimensions of the heart, are less in the woman than in
the man. ” Memoir es de la Soci'ete Medicate d' Observation de Paris. Tome Premier,

1836. pp. 282, 283.

CORRIGENDA.

Page 54, note , line 4 from bottom, for del read dei.

„ 137, „ for xi. read ii.

,, 165, ,, for communicatione read communication.

,, 267, „ for first read second.

„ 283, line 6 from top, for weeks read beats.

„ 581, line 3 from bottom, for Gardiner read Gairdner.

CONTENTS.

CHAPTER I.

Inflammation of the Heart and its Membranes, 1

CPIAPTER II.

Diseases of the Valves of the Heart, 128

CHAPTER III.

Diseases of the Muscular Structures of the Heart, .... 255

CHAPTER IV.

Weakness or Deficient Muscular Power of the Heart, . . . 298

CHAPTER V.

Fatty Degeneration of the Heart, 302

CHAPTER VI.

Treatment of the Organic Diseases of the Heart, 341

CHAPTER VII.

On the Condition of the Heart in Typhus Fever, 3GG

XVI

CONTENTS.

CHAPTER VIII.

Page.

Displacement of the Heart, 452

CHAPTER IX.

Rupture of the Heart, 4C5

CHAPTER X.

Deranged Action of the Heart, 481

CHAPTER XI.

Aneurism of the Thoracic Aorta, . 537

CHAPTER XII.

Aneurism of the Abdominal Aorta, . 610

Table of Cases, 651

Index, 659

A TREATISE,

&c. &c.

PART I.

DISEASES OF THE HEART AND AORTA.

CHAPTER I.

INFLAMMATION OF THE HEART AND ITS MEMBRANES.

Of the three forms of this disease described by authors, namely,
endocarditis, myocarditis, and pericarditis, the last demands our
especial attention, from its greater frequency, and from the marked
character of its signs. Inflammation of the muscular portions of
the heart, occurring independently of a corresponding state of
either or both of its investing membranes, must be a very rare
affection ; and we are still but imperfectly acquainted with the
history and symptoms of endocarditis. In most of the severe
cases of carditis, the three great structures of the heart are pro-
bably engaged ; and even though the muscular tissue may not
exhibit the evidences of organic change, yet the signs of its irri-
tative excitement and subsequent paralysis are plainly to be re-
cognised. In truth, if we except the pain which so commonly
attends serous inflammations, the remaining symptoms of peri-
carditis are to be referred less to the pericardium than to the
muscular fibre.

It is true that the endocardium frequently participates in the
disease, although, pending the violence of the attack, the evi-
dences of this lesion may be obscure or wanting. It does not

VOL. I. B

INFLAMMATION OF THE HEART.

appear possible to determine the presence or absence of endo-
carditis in the earlier periods of acute pericardial inflammation.
The cardiac excitement can be otherwise explained, and even if
the occurrence of valvular murmurs were diagnostic, their exist-
ence would be difficult or impossible to detect, from their being
masked by the more prominent phenomena of acute pericarditis.

It is also true that in many cases of pericarditis a murmur is
detected when the disease has been subdued, and all pressing
danger removed ; and this murmur may be permanent, and con-
tinue for months or years, till the patient die with the symptoms
of valvular disease. Here we must believe that an inflammation
of a valve has set in, either simultaneously with, or immediately
subsequent to, the attack of pericarditis ; and the frequency of
this occurrence has led to the opinion, not only that pericarditis
is commonly combined with endocarditis, but that many cases
of the valvular diseases of the heart arise from inflammation of
the endocardium. Yet we must be cautious in admitting these
conclusions to their full extent. It may occasionally be found
that the murmur, after existing for a period more or less extended,
disappears, leaving the sounds of the heart in their natural condi-
tion, and the patient remains free from symptoms of valvular dis-
ease. The mere occurrence of murmur, even though immediately
consequent on pericarditis, is not necessarily indicative of pro-
gressive valvular disease.

We are still unable to explain this occurrence satisfactorily.
Is the murmur produced by a passing endocarditis which is not
followed by organic change or deposit? Is it induced by atony
of some portion of the muscular fibre, or may the cardiac orifices
be altered by irregular or tonic spasm of the heart ? This much
is certain, that the occurrence of murmur following pericarditis
should not necessarily lead to the diagnosis of valvular disease,
in the ordinary acceptation of the term.

On the other hand, it too often happens that a violent attack
of pericarditis may, under proper treatment, be subdued, and then
the patient, having lost all symptoms of the malady, is considered
as cured, and allowed to return to his usual habits. But in a short
time a bellows murmur is established, which remains, with but
little variation, for a long period, when the signs and symptoms

PERICARDITIS.

of organic disease become manifest. This murmur is generally
single, and accompanies the first sound, while the second remains
unaffected. It obviously arises from disease of the endocardium,
in all probability inflammatory, which has either co-existed with
the pericarditis or has set in immediately subsequent to it. To
the watchful physician there cannot be a time more full of
anxiety than that immediately following the apparently success-
ful treatment of an attack of acute pericarditis. Should Ins pa-
tient recover without the development of murmur, all is well;
but the occurrence of this sign, and its permanency, are calculated
to depress and discourage him in the greatest degree.

PERICARDITIS.

The earlier descriptions of this disease give but an erroneous
idea of the affection, principally from this circumstance, that
its more violent forms alone have been described. More recent
investigations, however, show that the disease may occur in
many gradations of intensity, and that it is frequently met with
in such a mitigated form as really to present no symptoms by
which it might even be suspected ; in fact, in a form where its
existence is only discoverable by physical examination. The
idea of pericarditis is connected, in most men’s minds, with
severe and manifest symptoms, such as pain, tumultuous and
irregular action of the heart, special modifications of the pulse,
syncope, and so on, and it consequently happens that the disease is
often overlooked. In some instances this is of little importance,
as the processes of inflammation, exudation, and adhesion, go
on to a favourable termination, without any medical interference,
and the patient recovers from pericarditis, his physician being
ignorant that he ever had any such affection. But in other cases
the neglected inflammation, at first mild and unimportant, sud-
denly assumes a more virulent character, and the symptoms of
pericarditis are developed when it is too late to overcome them
by treatment.

In a practical point of view we may divide the cases of peri-
carditis into three classes. In the first are to be placed those in
which there is but a slight, though general effusion of coagulable
lymph. In the second we have superadded, the secretion of serum

b 2

INFLAMMATION OF THE HEART.

in abundance, causing distention of the sac. And in the third
class we find, in addition to the preceding conditions, the signs
of muscular excitement, if not of myocarditis.

Let us contrast these forms.

First Form.

Absence of pain or lo-
cal suffering frequent.
No sign of muscular ex-
citement, nor any special
character of pulse. No
increase of dulness over
the heart.

Second Form.

The local and general
symptoms more decided,
though often very trifling.
Irregular action of the
heart and pulse, often
more manifest in the
advanced periods. Re-
markable increase of
dulness over the heart.

Third Form.

Local distress, often
extreme even at the
outset. Tumultuous ac-
tion of the heart. Irre-
gularity of pulse. Dysp-
noea, orthopnoea, oedema-
tous swellings, syncope,
death.

These forms are not merely different in the degree of violence
of the disease, but draw their distinctive characters from other
circumstances. That there is a progressive increase in the vio-
lence of the original inflammation, as we ascend from the first to
the third form, may be admitted. The great characteristic of the
second form, however, is the effusion of fluid, while that of the
third is the irritative or inflammatory excitement of the muscles
of the heart. It is this which causes the great suffering, and, as
we shall presently see, constitutes the danger in the advanced
stages of the disease; for there can be little doubt that death
occurs by syncope, induced by paralysis of the left ventricle, the
result of its preceding excitement or inflammation. The muscles
of the heart are then in the same condition as that of the inter-
costals after violent pleuritis ; and when the weakened organ has
not only to propel the column of blood, but to struggle with the
pressure of a large body of fluid, while its action is clogged by a
deposit of coagulable lymph, it is no wonder that it should fail to
fulfil its function.

In explaining the mode of death in pericarditis, however, too
much importance has been attached to the effect of pressure by
the superincumbent fluid. It is singular how much pressure the
heart is capable of bearing without any important disturbance of
its functions. Thus in dislocations to the right side from an em-
pyema of the left pleura, though the pressure exercised must be

PERICARDITIS.

much greater than that in an ordinary case of pericardial effusion,
the action of the heart is rarely disturbed. I have published a case
in which pericarditis attacked a heart thus displaced, yet without
any injury or disturbance of the action of the organ; and Mi.
Adams has observed a case of long-continued pressure of the heart,
so great as to fold up part of one ventricle, in which the heart
endured this effect for a considerable length of time.

If we again refer to the analogous case of the intercostal mus-
cles and diaphragm in pleurisy, we find that these muscles aie
capable of resisting an amount of pressure greater than that which
occurs in most cases of pericardial effusion. Distention of the side,
dislocation of the heart, and of the lung, may be observed before
any yielding of the muscular portions of the chest ; so that the con-
clusion is forced upon us, that, so long as the contractility of the
fibre is not weakened by disease, all these muscles are capable of
bearing a great increase of pressure without their functions being
suspended.

Two conditions of the muscles may be supposed to exist.
One, simple atony or paralysis ; the other a true myocarditis,
attended with deposition of new matter among the fibres, or by
ulcerative absorption. In the first of these conditions recovery is
possible, just as we see in pleuritis that the action of the paralysed
intercostals is restored, while in the second the organ appears
to be irreparably injured.

We may then conclude, that when death takes place as a con-
sequence of pericarditis, the contractile power of the left ventricle
at least has been seriously injured, and that the organ is either
simply paralyzed, or that its structure has been altered more or
less deeply by inflammation of the fibres themselves.

When we examine the pathology of myocarditis we shall
return to this subject.

But it must not be forgotten that in many cases of severe peri-
carditis there is complication with other diseases, local or general,
and that we may be in error in attributing death to the cardiac
inflammation alone. The patient may die with a severe pericar-
ditis, but not necessarily from the effects of the local disease, sim-
ply considered. That such was the nature of many of the severe
cases given by Louis appears certain. In his first case the disease
affected not only all the structures of the heart, but also the lungs,

INFLAMMATION OF THE HEART.

stomach, and hepatic portion of the peritoneum. In another case
the affection Avas evidently connected with intermittent fever and
nervous disease. In a third case the pericarditis was complicated
with delirium tremens, which had been improperly treated, and
extensive gastro-pulmonary disease.

Of this combination I have seen several examples, in which
the pericarditis, though intense, was but one of a group of irrita-
tions, all of them secondary to, or at least complicated with that
form of typhus or typhoid fever which follows on an excessive
debauch and exposure to cold, and which sets in and is accompa-
nied with delirium tremens.

In this terrible disease, we may sometimes find a true typhus
fever, with characteristic petechia?, while in other cases the fever
is of a typhoid type, in connexion with a group of local inflamma-
tions. This disease is generally fatal. I have found cerebritis,
bronchitis, gastro-enteritis, double pneumonia, and pleurisy, co-
existing with the pericarditis in these cases.

We may divide the cases of pericarditis into the uncomplicated
and complicated forms. Under the first head, however, we include
those cases in which the muscular structure and the endocardium
may be engaged.

Uncomplicated.

a. Inflammation of the serous membrane alone.

b. Inflammation of the pericardium with combination of

endocarditis and possibly of myocarditis.

Complicated. — Under the head of complicated pericarditis we
may make two great divisions :

a. Complication with general disease.

b. Complication with one or more local diseases of

structures unconnected with the heart.

Under the first of these heads may be arranged the following
cases : —

a. Combination with rheumatic fever.

b. Gout.

c. Phlebitis.

d. Typhus fever.

e. Dropsy.

f. Delirium tremens.

g. Intermittent fever.

PERICARDITIS.

Under the second we may enumerate a great number of
examples, most of which must be familiar to the clinical ob-
server.

a. Pericarditis associated with pleuritis, which is gene-

rally of the left lung.

b. Combined with pleuro-pneumonia of one or both

lungs.

c. Associated with a group of typhoid inflammations.

d. Superadded to chronic hypertrophy of the heart.

e. Acute pericarditis supervening on a chronic em-

pyema.

f. In connexion with fatty degeneration of the heart.

g. Induced by ulcerative perforation of the pericar-

dium.

To this list many other examples of the association of peri-
carditis with diseases of various organs might he added.

On taking a review of the symptoms of pericarditis, we find
that, as the disease may occur under a great variety of circum-
stances, its symptoms present a singular want of constancy in
character. The disease may be absolutely latent, so far as symp-
toms are concerned, or be indicated by signs of extreme cardiac
and general suffering. The picture of the affection, as given in
the older nosological works, only belongs to the more violent
forms, and is imperfect even with respect to them. But while the
symptoms are so varied, the physical signs are constant, and of
easy interpretation, and the same principles of diagnosis apply to
every form of the disease. And it must be admitted that, of all
the thoracic diseases, there is none of which the diagnosis so much
depends on physical investigation. Hence, as the signs are so well
marked, their study will give us a more comprehensive view of the
various stages of the affection than we could get by examining
the symptoms in the first instance. We shall then examine some
cases illustrative of the different forms of the disease, and its com-
binations, and so be enabled to study its general history with
reference to vital symptoms.

Let us then examine the physical signs in this affection.

Up to the year 1833, when the signs of pericarditis were more
carefully studied, the diagnosis rested mainly on negative evidence,

INFLAMMATION OF THE HEART.

that is to say, that in a case of manifest inflammation within the
thorax, if we could satisfy ourselves that the disease was neither
pleuritis nor pleuro-pneumonia, we might, with great probability
of being right, make the diagnosis of pericarditis.

In the year 1824, in a work by Dr. Collin, we have the first
notice of the physical signs of pericarditis. The following are his
observations on this subject:

“We have only once observed the sound analogous to the
creaking of new leather. It occurred in a patient who died of
chronic pericarditis. This sound continued for the first six days
of the disease, but disappeared as soon as the local symptoms in-
dicated a slight liquid effusion into the pericardium. M. Dervil-
liers, intern pupil at the Hospital of St. Antoine, observed it at
the same time in a patient whose symptoms indicated pericarditis.
He was not aware that the phenomenon had been already ob-
served in this disease, and did not avail himself of it in his diag-
nosis. In this case it is to be regretted that no dissection was
recorded. On another occasion M. Dervilliers examined the body
of a man who had presented this phenomenon during the whole
of his stay in hospital. A chronic pericarditis, producing thick,
false membrane, and numerous vegetations over the heart, was
discovered ; the number of adhesions was small, and the pericar-
dium did not contain a single drop of serosity. Perhaps this
sound would be a constant symptom of pericarditis before the
occurrence of liquid effusion, fugacious in cases where the disease
runs its course in a short time, but of longer duration in chronic
cases” a.

Collin referred the friction sound, as observed by him, to a
dry state of the serous membrane, the first effect of its inflamma-
tion, and compared it to the sound produced in certain cases in the
knee, when we produce a friction between the patella and the con-
dyles of the femur. There are, however, strong grounds for be-
lieving that the friction sounds in pericarditis indicate that lymph
has already been effused. From the rarity of death in the very
first stages of the disease, it becomes difficult to declare that
a merely dry state of the membrane will not suffice to produce

* Les diverses Methodcs d’Exploration de la Poitrine.

PERICARDITIS.

the sign, and there seems no reason why it should not do so. On
the other hand, it is certain that in all the cases in which a double
friction sound was observed, and in which there was a dissection,
lymph was found covering the pericardium. The researches of
Dr. Mayne show that in cases where the symptoms and subsequent
phenomena concurred in proving the existence of an incipient
pericarditis, some time elapsed before the friction sound was de-
veloped. I have myself verified this observation of Dr. Mayne’s.

It is admitted that in the natural state of serous membranes,
the gliding of one surface on the other, so as to produce the least
possible amount of friction, is admirably provided for by the ex-
quisite smoothness of the surfaces, which are further bedewed with
a lubricating exhalation. Should the surface, under the influence
of inflammation, become merely dry, it is almost certain that some
friction phenomena would be developed, particularly in the peii-
cardium, where the membrane is pressed upon by the compara-
tively firm and unyielding mass of the heart. But this state can-
not continue long, and, though unable to point out the exact time
when the friction sounds from mere dryness pass into those pro-
duced by a roughened state of the surface, we need not regret
the difficulty, as it must have relation to but a short portion of
time, and does not bear on any practical question.

In the roughened state of serous membranes from inflamma-
tion and exudation of lymph, two classes of phenomena are pro-
duced :

First. Sounds having a generic character, yet varying accord-
ing to the different physical conditions of the parts. They have
been termed the friction sounds.

Second. Phenomena discoverable by the touch. For example,
when the hand is applied over the region of the inflamed organ,
sensations as of two surfaces rubbing and grating one on the other,
are often perceptible. These signs are of more rare occurrence
than the former, and are often absent when the sounds are mani-
fest. They imply that the lymph is in a state of unusual consist-
ence or hardness, and probably also that the surface is but little
bedewed with serosity. And hence, as might be expected, they
are generally better developed during the earlier periods of the
disease than when, after the absorption of the serous part of the

INFLAMMATION OF THE HEART.

effusion, and under the process of cure, the surfaces again come
into contact.

Among the conditions which favour the production of friction
signs perceptible by the hand, the resisting nature of the organ
covered by the inflamed membrane occupies a prominent place ;
and it is probable that the greater frequency of these signs in pe-
ricarditis, rather than in pleuritis, is referable to the unyielding
nature of the structure of the heart, as compared with that of the
lung. Whoever has once grasped the living heart of an animal,
can understand what a hard and solid mass it presents during the
systole. We further find, that, in the case of peritoneal friction,
the sign has been principally observed where the inflamed mem-
brane invests some organic tumour or solid viscus. Can we then
explain the rarity of the tactile friction signs in the advanced and
resolutive stages of pericarditis, by supposing a weakened state
of the heart, which interferes with the vigour of its contractions,
and renders it, during the systole, less hard and resisting?

Third. Signs discoverable by percussion. In many cases of
simple pericarditis, where the heart has not been previously dis-
eased, the sound on percussion over the organ remains unaffected;
but when the pericardium is distended by solid, fluid, and gaseous
secretions, modifications of the sound, with reference to its cha-
racter and to the extent of dulness, are always produced.

GENERAL ADHESION OF THE PERICARDIUM.

The occurrence of obliteration of the sac of the pericardium has
been enumerated among the causes of some organic diseases of the
heart, especially of its hypertrophied and dilated conditions. It
is supposed that, from the difficulty experienced by the heart in
contracting under this condition, the muscles increase in strength
and volume, until a true hypertrophy is induced. This doctrine,
so far as it relates to the production of hypertrophy in conse-
quence of adhesion of the pericardium, must not be admitted in
its full extent, notwithstanding that it has been strongly advocated
by Dr. Hope. “ I have never,” he says, “examined, after death,
a case of complete adhesion of the pericardium, without finding
enlargement of the heart, generally hypertrophy with dilatation.

PERICARDITIS.

This sufficiently demonstrates the tendency of the affection' a. In
another place he observes : “ How adhesion occasions hypertrophy
is easily understood, for, first, inflammation is probably a cause
of hypertrophy, and secondly, the organ must increase its con-
tractile energy in order to contend against the obstacle which the
adhesion, by checking its movements, presents to the due discharge
of its functions, and, as explained in the article on hypertrophy,
increased action leads to increase of nutrition.

it The cause of the co-existent dilatation is not less manifest.
As the shackled organ transmits its contents with difficulty, it is
constantly in a state of greater congestion than is natural, and, as
is more fully explained in the article on dilatation, permanent dis-
tention is the most effective cause of this affection. When the
muscular substance has been softened by the previous inflamma-
tion, as frequently happens, dilatation takes place much more
readily, in consequence of the deficient elasticity or tone of the
heart’s parietes”b.

Without denying that a general adhesion may induce hyper-
trophy and dilatation, experience leads me to doubt that such an
effect necessarily or even commonly follows the condition indi-
cated. I have often found the heart in a perfectly natural con-
dition, with the exception of an obliterated pericardium. It was
neither hypertrophied nor atrophied, and the patient had exhi-
bited no symptoms of heart disease for many years before death.
In one case, seven years had elapsed between the death of the
patient from hepatic disease, and the attack of pericarditis which
obliterated the sac. During this period no symptoms of disease
of the heart were manifested. Again, if we take the cases of sim-
ple pericarditis with recovery, we cannot doubt that adhesion
more or less complete has occurred ; and yet any increased liability
of such patients to enlargements of the heart has not come under
our observation. It is in those cases of pericarditis which we have
before indicated, and where valvular disease is either co-existent
with or subsequent to the first inflammation of the sac, that hy-
pertrophy and dilatation appear as remote consequences of peri-
carditis. In the cases of recovery without murmur, we have little
apprehension of the after-occurrence of organic disease.

a Last edition, p. 181.

b Ibid. p. 182.

INFLAMMATION OF THE HEART.

It lias been stated to me by Professor Smith, that he has found
general adhesion of the pericardium coinciding with atrophy or
with hypertrophy of the heart, in a nearly equal frequency. In
some of the cases of atrophy the change was simple, consisting
essentially in a diminished volume, with perhaps a paler colour,
of the heart, while in others a true fatty degeneration had com-
menced. In another series the heart showed the fatty degenera-
tion invading, more or less completely, the entire of the cardiac
walls. And it is a remarkable fact, recorded by the same observer,
that he has always found ossification of the pericardium, which
we may hold as the extreme of the obliterating process, attended
with atrophy of the heart.

The application, then, of the doctrine that muscle increases in
volume and force in proportion to the resistance to its action,
must he received in a qualified manner when we apply it to the
elucidation of diseases of the heart. It is true that we often see
hypertrophy of that cavity of the heart which has to propel blood
through a diminished valvular orifice; hut we may fairly draw a
line between the cases of obstruction to muscular action from
obliterated pericardium and valvular disease. In one, as in adhe-
sion, the normal condition of the muscle is interfered with, and so
the contraction diminished; while in the other the muscle, being
free to act, increases in power, just as the voluntary muscles do
when trained by exercise.

Analogy seems to favour views contrary to those of Dr. Hope.
Obliteration of the pleura is commonly followed by a diminished
volume of the lung. In chronic peritonitis with general adhesion,
the intestinal tube is more frequently found thinned, contracted,
and weakened, than in the opposite condition. And were we to
extend our examination to the case of the voluntary muscles, it
would not be difficult to demonstrate that the existence of a me-
chanical obstacle to their free contraction is followed by atrophy.

On the whole we may conclude, —

First. That obliteration of the pericardium does not necessa-
rily induce any manifest change in the condition of the heart.

Second. That, where alteration of the muscular condition of
the heart is found in connexion with this obliteration, it is not
necessarily a state of hypertrophy, but is often one of an opposite
nature.

PERICARDITIS.

Third. That the cases of valvular obstruction and of adhesion
of the pericardium are not parallel, inasmuch as that in one case
the heart is free to act, while in the other its motions are pre-
vented or interfered with.

Fourth. That obliteration of other serous membranes is more
often followed by atrophy than by hypertrophy of the subjacent
organs.

Fifth. That atrophy of the voluntary muscles is the ordinary
effect of whatever interferes with their free action.

There is a case, however, which, in this inquiry, must not be
passed by without notice, namely, the existence of a true muscular
aneurism of the ventricle, co-existing with an adhesion which
corresponds to the tumour or sac. It is difficult to say whether
this adhesion is the cause or consequence of the aneurism. Yet, if
we adopt the first opinion, it still does not go far in strengthening
the views of Dr. Hope, for we can easily understand that, while
the rest of the heart remains free to act, the adherent portion will
be first impeded, then paralyzed, and finally yield, so as to allow
of a local accumulation of blood. Here it is partial adhesion
which causes dilatation, and we cannot infer from this that a ge-
neral adhesion would induce hypertrophy.

If, however, we adopt the opinion of Rokitanski, that par-
tial aneurism of the heart arises from an inflammatory action ori-
ginating in the endocardium or in the muscle, we can comprehend
how a partial adhesion would be produced, and stand then as a
consequence and not a cause of the disease11.

PHYSICAL DIAGNOSIS.

It is plain, that as the physical diagnosis of pericarditis depends
on the existence of some of the products of inflammatory secre-
tion within the sac, we cannot directly apply it to the very first
stage of the disease. In this respect, however, pericarditis forms
no exception, as in all other diseases of the chest a mechanical
alteration of some kind must exist before physical signs are pro-
duced. The first stage, then, of pericarditis, or that anterior to
any change of the surface of the sac, is undiscoverable by physical

1 See also Hassc’s book, translated by Dr. Swaine. Sydenham Society, 1845, p. 141.

INFLAMMATION OF THE HEART.

means. But it does not follow that the use of auscultation is of
no avail even under these circumstances, for we may often be led
to a suspicion of pericarditis by finding that there are no physical
signs of inflammation of the lung or endocardium.

How long this state of pericarditis may last it is difficult or
impossible to state, but the period is generally so short, that the
detection of the disease on its entry into the second stage, or that
in which it affords physical signs, is sufficiently early for all prac-
tical purposes.

We owe to Dr. Mayne an important series of observations of
pericarditis, in some of which the patient was under observation
for a certain time preceding the appearance of physical signs. In
the first case it was not until the third day after symptoms of peri-
carditis had set in, that physical signs were discovered, although
on each day the stethoscope was carefully employed. The symp-
toms were great epigastric tenderness, particularly severe when
pressure was directed towards the pericardium ; an extremely dis-
tressing sense of weight about the heart, the impulse of which
was very strong, but regular; the pulse 130, small, wiry, and re-
gular. The patient was treated for acute pericarditis, yet the
friction sounds did not appear until the third day of the disease,
so that the pericarditis must have existed certainly for twenty-
four, and probably for thirty-six hours, before physical signs were
produced. In another case the same period seems to have elapsed
between the invasion of the disease and the appearance of the
friction signs. The impulse of the heart was very great, contrast-
ing remarkably with the pulse at the wrist, which was rapid and
small ; the sounds of the heart were rapid, but unaccompanied by
friction, and the impulse communicated a considerable shock to
the ear; friction signs were not observed until the third day of
the pericarditis.

It is possible that the period anterior to the formation of lymph
in these cases might have been forty-eight hours, but it is very
probable that it was much less. Dr. Mayne concludes that in the
present state of our knowledge there is no stethoscopic sign which
can be considered pathognomonic of the first stage, which, he says,
is the more to be regretted, as this is, of all others, the period at
which most benefit might be expected from active antiphlogistic

PERICARDITIS.

treatment. It has been already observed, however, that pericar-
ditis, as to its want of physical signs in the first stage, forms no
exception in the class of thoracic diseases ; it would be well, in-
deed, if every acute disease could be positively ascertained within
thirty-six hours of its invasion ; and it is possible, too, that the
omission of that active antiphlogistic treatment, still so often em-
ployed in the first stages of inflammation, might be of no great
detriment to the patient.

This practical lesson, however, is derivable from what has
been said, namely, that in a case of suspected pericarditis in its
early periods, the absence of friction signs must not lead us to
conclude that the pericardium is safe. I have known several days
to elapse before the appearance of friction signs, in a case where
pericarditis was superadded to inflammation of the left pleuia.

Finally. If the disease be of a violent and dangerous character,
we shall almost certainly have symptoms of a special nature to
guide us, before the appearance of the friction signs. And on
the other hand, if the case is a mild, dry pericarditis, there is no
great chance of injury to the patient from its being overlooked
for one or even two days.

The physical signs of pericarditis may be classified as follows :

First. Sensations of friction communicated to the hand. T o
these we may give the general term of tactile signs.

Second. Friction sounds ; the “ attrition murmurs " of Hope.

Third. Extension of dulness over the heart, resulting from
liquid effusion.

Fourth. Friction signs attended with or preceded by valvular
murmurs.

Fifth. Signs of eccentric pressure analogous to those of em-
pyema.

Sixth. Signs of excitement of the heart.

Seventh. Signs of weakness or paralysis of the heart.

It may be stated generally that the tactile and acoustic signs
vary according to the following circumstances : —

1. The state of the effused lymph.

2. Its extent.

3. The existence or non-cxistence of fluid.

INFLAMMATION OF THE HEART.

4. The advance or arrest of the process of organization.

5. The process of obliteration of the cavity.

6. The repetitions of inflammation.

I have already indicated these conditions in my original me-
moir ; the following, however, must be added : —

7. Tire existence of air in the pericardial sac.

8. The distention of the stomach with air.

9. The combination with pleuritis of the left lung.

10. The force and volume of the heart.

11. The combination with recent or previously existing dis-
ease of the valves.

There is no serous inflammation which presents such a differ-
ence in the physical constitution of its products as pericarditis,
and hence the friction phenomena in this disease are more singu-
lar and varied than in peritonitis or pleuritis ; and they further
present more remarkable changes in short spaces of time. The
products of inflammation present every form of effused lymph.
It may be as hard as cartilage, or form a soft, diffluent coating or
net-work over the heart; again, serous or bloody fluid, in various
quantities, may be also effused ; or the heart may be found bathed
in a homogeneous purulent liquid, or with its surface completely
studded over with minute warty masses, so as to resemble the
coarsest rasp3.

With the exception of the leather creak sound of Collin, and
some of the loudest rasping sounds, the friction phenomena are,
in general, singularly localized, and are not heard beyond the
actual region of the heart. In many instances we find that on
removing the stethoscope but a single inch from the spot where
the sound is loud, it totally ceases, although we still hear the ordi-
nary sounds of cardiac pulsation6.

a The production of an extremely indurated false membrane, as the result of acute
disease, is of importance, as we generally attribute induration to chronic disease. I have
communicated to the Pathological Society some examples of acute induration of the lung,
where the organ presented the hardness of chronic pneumonia. Dr. Corrigan, also, has
recorded similar facts.

6 Dr. Hope, when referring to this observation, says, that he suspects that the limi-
tation of the murmurs results from nothing more than their weakness, aided, perhaps, in
some cases, by their being generated on the posterior surface of the heart; “for,” he
observes, “ when a murmur generated on the anterior surface is loud, I see no reason

PERICARDITIS.

As might be expected, we find the most intense friction sounds
under two conditions : one a great degree of induration of the
lymph, and the other, the dry state of the surface. Under these
circumstances, the rasping and rubbing sounds are sometimes pro-
duced with extraordinary intensity, and it often happens, at least
in the earlier stages of the case, that the friction sensation is com-
municated to the hand.

In other cases, however, the sounds, though distinct, do not
convey the idea of so unequal and resisting a surface, but resem-
ble the rubbing together of two sheets of paper or parchment. In
such cases the lymph will probably be found of a soft consistence.
And there is a third class of cases in which the friction sounds
convey the idea of the rubbing together of two surfaces but little
roughened, and bedewed with a liquid secretion. The sounds in
such cases are sometimes so soft, equable, and gentle, as to render
it necessary that the patient should hold his breath for a few se-
conds in order that we may fully observe them.

It is not, however, to be believed that each of these modifica-
tions marks a separate case. In some instances of dry pericar-
ditis, the characters of the sounds undergo but little change, if we
except a gradual diminution of intensity ; but in other cases the
signs are presented in every possible variety of character.

The extent of the effused lymph materially affects the friction
signs. In most cases, at least before any process of adhesion has
commenced, the lymph is spread over the whole surface, and we
then observe the signs of friction with the systole and diastole of
the heart over the entire cardiac region. But friction signs con-
fined to one portion of the heart are commonly observed, and we
may divide such cases into two classes.

First. Cases where the signs are discoverable, in the earlier
periods, over but a limited portion of the heart. In this condition
they may continue, the disease appearing to remain singularly

why it should not be extensively propagated.” — Op. cit. On this I have only to remark,
that in my original memoir I merely stated the fact of the limited transmission of these
sounds, unless under certain circumstances ; and I have given a case in which the sounds
were extensively heard. I must add, that in many cases where the localization of the
signs was observed, the anterior as well as the posterior surface of the heart was com-
pletely roughened by exudation.

VOL. I.

INFLAMMATION OF THE HEART.

localized up to its termination in cure. We generally observe
these signs corresponding to the sides of the ventricles, rather
than to the apex or base of the heart.

Second. Cases in which, after the general extension of the
friction signs over the heart, adhesion takes place at the apex
and lateral portion of the ventricles ; under which circumstances
the friction sounds become localized, and often remain at the base
of the heart for a considerable period of time.

Although the modification of the friction sounds principally
indicated by Collin was the leather creak , “ bruit de cuir neuf yet
this appears to be the rarest of the forms met with. We are yet
ignorant of the exact nature of the conditions requisite for its
production, and can only say that it indicates dry pericarditis.
But we know that other forms of the friction sound are much more
frequent.

Two circumstances having the effect of modifying these sounds
must be here mentioned. One is the application of local anti-
phlogistic means ; and the other, the employment of pressure over
the heart.

Nothing, indeed, can be more remarkable than the rapidity
with which these signs are altered by the application of leeches
over the heart, by a blister, or a poultice. They change within a
few hours, even from the loudest rasp, with distinct vibration to
the hand, into a soft murmur, while the tactile signs disappear.
By this means we are sometimes, in cases of doubt, enabled easily
to distinguish between the pericardial and valvular sounds. I do
not believe that, to the well-educated ear, the difficulty of distin-
guishing these phenomena is as great as some writers have sup-
posed. Yet cases occur which, when seen for the first time, may
cause doubt. Phus the occurrence of a local pericarditis in a case
of pre-existing organic disease of the heart, is a combination that
may be difficult to determine. I lately saw a case of this kind
where the patient had long laboured under symptoms of disease
of the heart, probably the fatty degeneration. I found over the
light ventiiclc a rasping sound, and as I could not ascertain whe-
thei this was a new or a long-existing sign, I did feel difficulty in
diagnosis. The sign, however, as I was informed by the attending
physician, disappeared in a few days, after the application of a
blister and the use of a few mercurial pills.

PERICARDITIS.

I have spoken of the effect of pressure. If, while the stetho-
scope is applied, we make a strong downward pressure with the
hand, or increase the pressure of the head on the ear-piece, we
shall often find a notable increase in the loudness and distinctness
of the friction sounds; so that, in a case passing towards cure, we
may reproduce, to a certain degree, the harshness and loudness
which existed in the earlier periods of the attack. The same effect
can be even better produced by causing an assistant to make pres-
sure with the open hand over the cardiac region, during the ap-
plication of the stethoscope. As might be expected, this modifi-
cation by pressure varies directly as the elasticity of the chest. It
is very remarkable in children, in women, and in young, feeble
men”.

This mode of proceeding may be adopted in certain cases
where we are in doubt as to the nature of the sounds. I have not
made any extensive series of observations on the effect of pressure
in modifying the character of valvular murmurs, but it is certain
that the pericardial sounds are much more influenced by pressure
than those arising from valvular disease.

The complication with a liquid effusion modifies all the phe-
nomena of pericarditis. It may cause their suspension after the
disease has for some time existed in the dry state, while in the reso-
lutive stages of the case, its absorption is followed by their return.
It is also attended with changes in the sound of percussion over
the heart, the extent of dulness furnishing a measure of the effu-
sion. In fact, the phenomena of pleurisy with effusion, and of
pericarditis, are mutually illustrative ; and as in pleurisy it may
happen that, from the simultaneous effusion of lymph and fluid at
the commencement of the disease, we may get the signs of liquid,
without preceding friction phenomena, so in pericarditis the sac
may be distended without our having ever observed the friction
signs. But this occurs much more frequently in inflammation of
the pleura than in that of the pericardium.

Again, as in pleuritis the existence of a liquid effusion does
not necessarily prevent the occurrence of friction signs, so in pe-

1 This proceeding may be objected to by some, as productive of distress to the patient ;
but in most cases, unless in the earliest and most acute stages, pressure on the pericar-
dium does not cause any great inconvenience or suffering.

C 2

INFLAMMATION OF THE HEART.

ricarditis does the same rule apply. Of course, in both cases the
co-existence of friction sounds and extensive dulness is rare, but
of the fact there is no doubt, and I have ascertained that this
curious combination is much more frequently met with in peri-
carditis than in pleuritis. I have often found the friction sounds
to remain at the base of the heart, long after extensive liquid
effusion had taken place into the sac ; and it is particularly ne-
cessary to insist on this, as it has been stated by some writers,
that the third stage of pericarditis is not accompanied by frotte-
ment&.

In a case observed in the Meath Hospital some years ago, in
which there was extensive dulness, the friction signs could be
heard when the patient lay on his back, but disappeared on his
assuming the erect position. The explanation of this is obvious.
A case is given by Dr. Corriganb, in which the pericardium was
enormously distended, so as to reach to the first rib. When the
patient sat up, the friction sounds diminished, and sometimes
altogether disappeared, but became well marked whenever he lay
on his back. The heart was covered with a pulpy lymph, and
there was a vast effusion of liquid into the sac.

Having thus taken a general view of the direct signs of peri-
carditis, and the ordinary sources of their modification, let us, be-
fore alluding to some of the rarer phenomena, examine the succes-
sion of physical signs in the two principal forms of the disease,
namely, the dry pericarditis, and that which, at some period, is
attended with liquid effusion.

Case I. Simple Dry P encarditis. — Development of friction
sounds and tactile vibrations. The sounds may at first be general
or partial, and then spread over the whole surface of the heart.
They may be at first soft, but rise to a maximum of roughness and
loudness ; when they commence to decline, becoming softer and
more feeble. This change generally takes place first towards the
apex, and extends to the base of the heart. They finally cease,
the cardiac region remaining all the time with its natural sound on
percussion.

Case II. Pericarditis with Liquid Effusion. — Friction signs

a Dublin Journal of Medical Science, First Series, vol. vii. p. 278.

b See Transactions of the Pathological Society of Dublin, December, 1842.

PERICARDITIS.

are first developed with various degrees of intensity, but are ge-
nerally less loud and rough in this case than in the preceding one.
They soon disappear, either wholly or over a great extent, being
still heard in some cases, principally at the base of the heart. The
dulness diminishes, and with the return of clearness the friction
sians re-appear, though still generally feebler than in their first
stage ; then finally subside, leaving the sounds of the heart natural.
The tactile signs may or may not be present at the commence-
ment or resolution of the disease, but are seldom so well developed
as in dry pericarditis.

It is plain that in both these cases the diagnosis of an adhesion
of the pericardium, more or less complete, can be easily made,
not, however, from any direct signs of the condition itself, but
from the fact of our having observed the exudation of lymph,
with or without liquid, formed in a serous sac, and passing into
organization. I more than doubt that there is any certain physical
sign of adhesion of the pericardium, and have never been able to
verify the sign relied on by Dr. Hope of the double jogging im-
pulse. It appears more than probable that, out of the great num-
ber of cases observed in the Meath Hospital, where the numerous
changes of the friction signs were accurately investigated, many
of them resulted in adhesion rather than in resolution ; yet in
none was the sign in question developed after convalescence. In-
deed, from our general knowledge of the history of serous inflam-
mations, we must conclude that resolution without adhesion must
be of very rare occurrence in pericarditis; and consequently it is
fair to infer that in most of the cured cases of the disease an ad-
hesion has really taken place.

We may now consider the remaining causes of modification of
the friction signs.

I. Co-existence of Air with the usual Products of Inflammation.

There seems no reason to believe, that if air be occasionally
produced in the pleura or peritoneum, when in a state of irrita-
tion, that the same should not occur in the pericardium. On
this subject I have no anatomical evidence to produce, but I feel
satisfied that in one case at least I observed the phenomena of
pericarditis with pneumatosis. The patient was a young man of
lymphatic temperament, who had laboured under an attack of

INFLAMMATION OF THE HEART.

acute pericarditis for a few days before I saw him. On my first
examination he presented the usual signs of dry pericarditis,
with a considerable effusion of lymph of the ordinary consist-
ence. The rubbing sounds, though loud and distinct, had no-
thing unusual in their character, and the patient suffered but
little distress. After two or three days I saw him again,
and found that his state had become very much altered. His
appearance was haggard and worn, and he complained of ex-
treme exhaustion, which he attributed to a total deprivation of
sleep. This was induced by the extraordinary loudness and sin-
gular character of the sounds proceeding from the cardiac region;
for though up to this period the rubbing sounds were distinctly
perceptible by means of the stethoscope, the patient was quite
unconscious of their existence. They had suddenly, however,
become so loud and singular, that the patient and his wife, who
occupied the same apartment, were unable to obtain a moments
repose. On examination, a series of sounds was observable which
I had never before met with. It is difficult or impossible to convey
in words any idea of the extraordinary phenomena then presented.
They were not the rasping sounds of indurated lymph, or the
leather creak of Collin, nor those proceeding from pericarditic
with valvular murmur, but a mixture of the various attrition
murmurs with a large crepitating and a gurgling sound, while to
all these phenomena was added a distinct metallic character. In
the whole of my experience I never met so extraordinary a com-
bination of sounds. The stomach was not distended by air, and
the lung and pleura were unaffected, but the region of the heart
gave a tympanitic bruit de potfele on percussion ; and I could form
no conclusion but that the pericardium contained air in addition
to an effusion of serum and coagulable lymph.

In the course of about three days the signs of effusion of air
disappeared, leaving the phenomena as they were at the first
period of the case. The convalescence of this patient was slow,
and the rubbing sounds continued for an unusual length of time’1.
His recovery was ultimately perfect.

a There is a circumstance connected with this case worthy of being recorded as illus-
trative of the influence of the depressing emotions in retarding the processes of cure in
disease. After the disappearance of the signs of air, I was in hopes that the patient would

PERICARDITIS.

This case I believe to have been one of pure pneumo-pericar-
ditis. We have as yet no information as to this combination.
If vve refer to Laennec we find the observation that the temporary
existence of air in the pericardium causes a great degree of loud-
ness of the heart’s sounds; but he does not speak of the effusion
of air in connexion with actual pericarditis. Dr. Hope doubts
whether, in Laennec’s cases, the air was in the pericardium, and
suggests that the loudness of sounds was caused by the distention
of the stomach. It is remarkable, however, that in the case now
recorded we had both the symptoms and signs of pericarditis ; and
in addition to the clearest evidence of air in the pericardium, there
was this remarkable circumstance, that the sounds of the heart
were audible at a great distance from the patient.

Dr. Graves has observed a case of pneumo-pericarditis from
fistulous opening into the sac, which is of great value, as deter-
mining the character of the physical signs in this combination.

A woman aged 25 was attacked with acute hepatitis, which
ended in abscess. In a few days the hepatic tumour emitted a tympa-
nitic resonance. On the twelfth day from this occurrence she was
attacked with pains in the cardiac region, followed by violent beat-
ing of the heart, and a sensation of burning heat below the left
breast. On the next day she presented friction sounds of various
kinds over the heart, and these were soon complicated with a new
set of phenomena. Immediately under the mamma a peculiar
metallic click was occasionally heard, giving the idea of a fluid
dropping in the pericardium. This sound ceased when pressure
was made over the heart. On the third day from the invasion of the

be speedily restored to health ; but day after day elapsed, and no progress seemed to be
made in the organizing process. The rubbing sound remained unchanged, notwithstanding
the employment of all the means I could devise to bring the case to a successful
issue. I observed that the patient was depressed and melancholy, and on inquiring from
his wife whether he had any mental suffering, I was told that he had had great fears as to
his spiritual state, and was full of doubts on many points of his religious belief. Under
these circumstances I asked a clergyman distinguished for his talent and eloquence to
visit my patient. This interview was followed by the best results. Next day the rub-
bing sounds had become softer ; the visit was repeated, and on the third day all morbid
signs had disappeared. That the process of organization in this case was prevented or
delayed by the depressed condition of the patient’s mind, there can be no doubt. The
recovery of the patient was complete.

INFLAMMATION OF THE HEART.

pericarditis, rubbing sensation was communicated to the hand, and
the sounds assumed the character of an emphysematous crackling,
obscuring both sounds of the heart. This was most distinct along
the middle and inferior parts of the sternum, but could also be
heard to the left of the mamma. The metallic click became more
audible, but was not produced in a regular way. On the day
before death, a loud metallic ticking, audible at each stroke of
the heart, could be heard combined with the emphysematous
crackling and the other sounds. A slight bellows murmur ex-
isted at the region of the left nipple.

It was found that the sac of the hepatic abscess had formed
two openings — one near to the pyloric orifice, communicating with
the stomach, and the other passing directly through the union of
the diaphragm and pericardium into the sac. This perforation
was large enough to admit the middle finger. The pericardium
was intensely inflamed, and covered with great quantities of
lymph in various degrees of consistence.

This most important, and, as far as I know, unique case,
shows us an example of pneumo-pericarditis by fistulous opening,
and may be compared with the ordinary case of pneumothorax
by perforation of the pulmonary pleura. Here the supply of air
was manifestly from the stomach, taking a course through the
hepatic abscess in the first instance by the original perforation,
and from thence passing into the pericardium11.

If the preceding cases are compared, any doubt that could be
entertained as to the real nature of the first of them must be re-
moved ; for in both the physical signs were closely similar, and
they only differ by the addition of the signs of perforation in the
example described by Ur. Graves.

The following case of perforation of the sac, producing pneu-
mo-pericarditis, must be studied in connexion with that which

“ I have greatly abridged this case from Dr. Graves’s Clinical Medicine. It may be
placed in that important category of cases, which, independent of their rarity, may
be taken as introductory to the diagnosis of new forms or combinations of diseases,
or of affections previously known, but for the discerning of which no clear rules existed.
It is to the diagnosis of pneumo-pericarditis by perforation, what Dr. Beatty’s case of ab-
dominal aneurism, and Dr. Adams’ of fatty heart, are to the diagnosis of the respective
diseases of which they furnish examples. See Dublin Hospital Reports, vols. iv. and v.

PERICARDITIS.

lias now been given. For the particulars of this case I am in-
debted to Dr. B. M‘Dowel. The post mortem appearances were
exhibited at the Pathological Society of Dublin.

A policeman, aged 29, of robust frame, was admitted into the
Whitworth Hospital in July, 1846, complaining of cough and
other anomalous symptoms. Pie stated that a month before his
admission to hospital he had exposed himself to cold by taking
off his coat whilst in a profuse perspiration. This was followed
in the course of three or four days by a severe stitch, low down in
his right side ; for this he had himself bled, and experienced re-
lief from the operation. In a few days, however, pain of the same
kind returned, but now it was confined to his left side. He had
himself blooded a second time, but without experiencing any ad-
vantage. He had at this time also profuse perspirations, cough,
and some pain in his chest, but no rigors. The matter expecto-
rated was of a dark colour.

On this man’s admission to hospital, which took place a month
after the commencement of the above symptoms, no physical
evidence of disease could be discovered in either side ; but after
some days he was attacked by a stitch in his right side, which was
relieved by a blister ; he very soon after, however, began to com-
plain of pain in his left side ; this soon became agonizing, and at-
tended with severe dyspnoea. The day after, the following were
the symptoms and signs observed: — The expectoration had be-
come copious, purulent, and fetid ; his breath was also extremely
fetid. Dyspnoea, amounting to orthopnoea; voice faint, at times
nearly extinct. Countenance haggard, pale, and anxious. Pulse
110, weak. Some cough. Delirium at night, and slight diarrhoea.
The physical signs gave evidence of a large cavity, containing
air and fluid, in the antero-inferior region of the left side of the
chest; here was heard metallic tinkling, bourdonnement ampho-
rique, and splashing of fluid, caused by the action of the heart;
these sounds were produced by making the patient breathe deeply,
and with them could be heard faintly the normal cardiac sounds,
but no respiratory murmur. Percussion yielded a perfectly clear
sound over these regions ; but it was clearer than that yielded pos-
teriorly over the corresponding part of the lung, although no part
ol this side was dull ; the respiration in the upper part of the left

INFLAMMATION OF THE HEART.

lung was faint. Posteriorly from the centre downwards frotlement
was audible ; and over the base of the same lung a coarse crepitus
was heard. No local fremitus on either side, owing to weakness of
voice. In the right lung a fine crepitus was audible over the base
posteriorly. Anteriorly, and circumscribed to a limited space,
about the eighth rib, below the mamma, was heard a whiffling
sound, resembling cavernous respiration. The symptoms and
signs of respiration, as described, continued, with the exception of
dyspnoea, which was relieved by opiates : — He, however, became
delirious on the 26th of July, and died during the night, six days
from the supervention of the violent symptoms.

Dissection, twelve hours after death : — On opening the tho-
rax, a greatly distended pericardium, concealing the left lung,
was brought into view ; and on cutting into it, evidences of in-
tense inflammation were seen. The sac was greatly thickened,
and lymph, rough like mortar, lined its opposed surfaces; it con-
tained about six ounces of pus, having the consistence and
colour of milk. A round fistula existed on the right wall of the
sac, which led into a small anfractuous cavity, near the second
fissure, in the upper lobe of the right lung; this contained matter
similar to that found in the pericardium. The bases of both lungs
were solidified from a double cause, first, from a deposit of miliary
tubercle, and secondly, from pneumonia. Apices of both lungs
healthy. Universal inflammation of the left pleura, with lymph
spread over its surface, but there was no adhesion. On passing a
current of air through the trachea, it was observed to rise through
the fluid contained in the pericardial sac ; the pericardium, when
cut into, contained air.

Let us compare this case with that given by Dr. Graves. In
both instances, a fistulous opening of the pericardium was fol-
lowed by sudden and severe pericarditis, and by the effusion of
air into the sac. In Dr. Graves’s case, the signs, though singu-
larly modified, were still those of pericarditis; while in that by
Dr. M'Dowel these were wanting ; and a group of signs, closely
resembling those of the ordinary empyema and pneumo-thorax,
were produced. This is probably to be explained by the greater
amount of the aeriform effusion, and by the character of the pro-
ducts of inflammation in this case. The heart was found bathed

PERICARDITIS.

in a creamy, homogeneous, purulent fluid : and it is almost certain,
that no friction sign ever was or could ever have been developed,
as we may suppose, that from the moment of the perforation, the
heart became enveloped by the contents of the abscess in the
lunga. The greater amount of air, too, may be referred to the
direct communication with the lung. In Dr. Graves’s case, on the
contrary, the air was derived from the stomach, and by a tortuous
course passed into the pericardium.

It is to be noted in this case, that there was not only no aug-
mentation of the sounds of the heart, but that they were rendered
feeble. Was this produced by the intervention of the aeriform
fluid, just as in pneumo-thorax the vesicular murmur becomes
indistinct or inaudible, even before the lung has completely col-
lapsed ?

Thus it appears that two classes of metallic phenomena of the
pericardium, very different in their cause and nature, may be met
with. In one class the character is from the actual existence of
air within the pericardium, while in the other it is caused by the
distention of a neighbouring viscus with air.

II. Distention of the Stomach with Air.

The influence of flatulent distention of the stomach, and in
some cases of the large intestine, in modifying the sounds on per-
cussion in hepatization of the lung, particularly on the left side,
has long been known. This condition often leads to errors. The
same cause affects all signs derived from auscultation ; and thus
we find that the crepitating and mucous rales of bronchitis and
pneumonia, the friction sounds of pleuritis, and, finally, the sounds
of the heart and the friction signs of pericarditis, may present a
distinct metallic character. I have observed this to affect every
morbid sign in a case of double pleuro-pneumonia and dry peri-
carditis.

With respect to the latter affection, however, we merely find
that the rubbing sounds are metallic, but there is none of the

a An important case is given by Dr. Mayne, in which about eight ounces of thin pus
were found in the sac of the pericardium. There were no false membranes, and no form
of friction sound was ever developed. I shall again allude to this case. See Dublin
Journal of Medical Science, First Series, vol. vii. p. 274.

INFLAMMATION OF THE HEART.

singular emphysematous crackling, the metallic click, or the loud
gurgling and churning of air and fluid that have been observed in
pneumo-pericarditis. As might be expected, too, this character
is temporary, and irregularly intermittent, and I have succeeded
in immediately removing it by the administration of a carminative
draught or a turpentine enema, and restoring to the thoracic sounds
their ordinary character8.

III. Modifications of the Fnction Sound from a Complication
with Pleurisy of the Left Lung .

Strictly speaking, the peculiarities thus produced have no re-
ference to any change in the acoustic character of the signs of
pericarditis, but arise from the production of similar sounds in the
pleura, which, as they correspond with the motions of the lung,
differ in rhythm from those of the pericardial disease.

It may be inquired, if we have such a condition of the pleura
as will give the ascending and descending friction sounds, may we

a Nothing can be more meagre than the information given by writers on diseases of
the heart on the subject of pneumo-pericarditis. Laennec says nothing as to its causes,
except when it arises as a cadaveric condition, or occurs in the last periods of life. Dr.
Hope doubts whether the cases indicated by Laennec were really examples of the disease
in question. Louis himself does not describe pneumo pericarditis, nor has he any case
of this condition resulting from ulcerative perforation of the sac : it is not even men-
tioned by him. Mem. sur la Pericardite. And Rostan merely suggests that the sensa-
tion of fluctuation observed by Senac and Corvisart may have been caused by this com-
plication. “ I have sometimes,” says Laennec, “ been able to announce its presence, from
the supervention of an increased resonance over the lower part of the sternum, and from
the existence of the sound of fluctuation produced by the action of the heart, and by deep
inspirations.” — Forbes’ Translation, chap. 24. The fact of our occasionally being able
to hear the heart at a great distance is dwelt on by him as an indication of pneumo-
pericardium ; yet it is remarkable that this sign was not present in either Dr. Graves’s
or Dr. M'Dowel’s cases. On the other hand, it existed in the case which I have recorded.
It may be that in fistular pneumo-pericarditis the sounds of the heart are not augmented,
from the want of that tension of the sac which we may presume to exist in effusions of
air, without fistula. A case, too, might be anticipated, in which a valvular fistula of the
pericardium might be attended with increased pressure of air within the sac. Bouillaud
gives a case by M. Bricheteau, in which a sound similar to that of water agitated by a
mill-wheel, was found in the pericardial region, and which evidently proceeded from the
alternating motions of the heart. On dissection, an effusion, resulting from chronic peri-
carditis, was found. The purulent matter was extremely fetid, and when the sac was
opened, a rush of gas escaped. In this case, also, percussion of the pericardium, practised
before the sac was punctured, gave the “ bruit de flot." — TraitS des Maladies du Cu:ur,
1836, p. 332.

PERICARDITIS.

not also have a sound of friction produced merely by impulse of
the heart against the pleura, thus causing three pleural friction
sounds ? It is further to be ascertained, that this sound, so unfre-
quent, may not occasionally be a double sound, for we know that
the heart often gives a double impulse, in which case four pleural
friction sounds might be produced. Lastly, it is possible, that if
we had the combination of pleurisy with pericarditis, not less than
six friction sounds might be developed. Of these two would be
those of the ascent and descent of the pleura, two from the double
impulse of the heart impinging on the pleura, and two from the
friction produced within the pericardium itself.

It is now several years since a case occurred in the Meath
Hospital, in which the sounds of the heart striking against the
pleura occurred. The signs, in addition to those ordinarily ob-
served in pleurisy, were the friction sounds of ascent and descent,
and a friction sound, attended with vibration perceptible to the
hand, and synchronous with the impulse of the heart, which con-
tinued when respiration was suspended. The sound ceased when
the patient assumed the erect position. On dissection, a very
small quantity of unorganized lymph was found at the posterior
surface of the heart, but the pericardium presented none of the
appearances usually observed in cases presenting distinct friction
signs. The pleura, on the other hand, was covered with a copious
exudation of lymph, which had become granular on its surface
and semi-cartilaginous in structure. It is to be observed that, in
this case, the heart was dislocated downwards from old emphy-
sema.

There is yet another source of multiplication of the sounds
in pericarditis, exclusive of any affection of the pleura. A
condition of the heart may be observed, in which one of the
sounds becomes, as it were, doubled. This may arise in nervous
cases, in carditis, and, as we shall hereafter see, in that condition of
the heart where inflammation of the organ is threatened. It is
rare, however, that its occurrence is found to modify the sounds
in pericarditis; yet I have observed a case where there was no
physical evidence whatever of pleurisy, yet in which the rhythm of
the heart was triple, one friction sound coinciding with the single,

INFLAMMATION OF THE HEART.

and two with the double sound of the heart. The case was one
of rheumatic fever of ten days’ duration, and the friction sounds
at first were feeble, and passing into a soft bellows murmur ; gene-
ral and local bleeding greatly reduced the heart’s action, and then
the friction phenomena became more distinct. In four days the
friction sounds were triple, and in the recumbent position accom-
panied with a metallic click, but this peculiarity ceased when the
patient sat up. In two days more the triple character of the
sounds disappeared, and in a short time all traces of pericarditis
had vanished.

As to the causes of this doubling of one of the sounds of the
heart, we can as yet offer no satisfactory explanation.

It is easy to comprehend, that, according to the relative rates
of rapidity of the cardiac and pulmonary actions, which will of
course vary in different cases, different rhythms or modes of suc-
cession of the sounds will be met with in different cases, or in the
same case at different stages of its progress.

V. Influence of the Force and Volume of the Heart.

It will be unnecessary for us to dwell at any length on the last
source of modification of the friction sounds, namely, the force and
volume of the heart. In general, other things being equal, the
loudness of the friction sounds will vary with the force of the
heart ; and we might imagine a case in which, notwithstanding the
existence of a quantity of lymph on the heart, the sounds would
be feeble or absent from the want of a sufficiently active muscular
contraction.

I have had but little experience of the influence of the volume
of the heart upon the sounds in pericarditis. I do not think that
in the combination of enlarged heart with inflammation of its se-
rous covering, there is any change produced in the nature of the
sounds ; but it seems probable, that the extent to which they may
be heard is increased. I have already noticed the remarkable fact
of the limitation of even the loud friction sounds to the cardiac
region, as one of great value in diagnosis. Yet we are not to infer,
that in cases of extension of the sounds the heart is necessarily
enlarged. The leather creak sound may be heard over the whole
chest without any enlargement of the heart; and in a case which

PERICARDITIS.

I have already published, and in another recorded by Dr. Watson,
the same result was found. The heart, in both cases, was thickly
studded with granules of a semi-cartilaginous structure.

Dr. Graves has some good observations, however, on the in-
crease of volume of the heart in causing extension of the friction
sounds. He gives a case of the combination of hypertrophy and
dilatation with pericarditis, in which the motions of the heart were
accompanied by two loud, prolonged sounds of equal duration,
but of different tones. The first was a bruit cle scie ; the second
was a musical sound, closely resembling that made by rubbing
the moistened finger on glass. These sounds were very distinct
under both clavicles, but were not heard in the carotid or subcla-
vian arteries. In the course of twenty-four hours the musical
sound changed to a well-marked leather creak.

The heart was found hypertrophied and dilated, and coated
with lymph, the most recent effusion of which appeared at its base ;
the valves, lining membrane, and blood-vessels, were all healthy.
A large quantity of fluid occupied both pleural cavities ; a circum-
stance considered by Dr. Graves to have been an additional cause
of the extension of the friction sounds, as it acted by pressing the
heart against the walls of the chest. It is remarkable that the
pulse was only 70 or 72“.

But, without denying that the existence of an enlargement of
the heart may cause an extension of the friction sounds, I believe
that this phenomenon will be found to depend more on the nature
of tbe sounds themselves, than on the extent of the inflamed sur-
face. We know that a great extension of sounds may occur with-
out alteration in the volume of the heart, and it is remarkable that,
in Dr. Graves’s case, even the musical sound was inaudible at the
apex of the organ.

On the whole, I incline to the opinion, that the mere enlarge-
ment of the heart only causes extension of these sounds, in virtue
of the greater amount of surface engaged ; so that, under these cir-
cumstances, the sounds, were it not for other conditions, would
not be audible beyond the actual region of the heart, although
this region was morbidly enlarged. I have already published a
case of a greatly enlarged heart, affected with pericarditis, in

a Clinical Medicine.

INFLAMMATION OF THE HEART.

which, although repeated observations of the state of the lung
were made, no friction sounds were ever detected, except over the
region of the heart; and these were only discovered on the day
before the patient’s death. The case, too, was one peculiarly
adapted for the extension of friction sounds, for the heart was not
only greatly enlarged, but presented the appearances of an acute
hemorrhagic pericarditis supervening on a chronic disease, as shown
by an effusion of lymph of a soft consistence, and of the colour of
blood, with, at the same time, vast depositions of a semi-cartila-
ginous hardness ; the heart’s action was strong, and the friction
vibration manifest, a point of importance to be observed, as it might
be supposed that the want of extension of friction sounds was
caused by the overlaying of the indurated lymph with the more re-
cent and softer effusion.

We have seen that in Dr. Graves’s case there existed copious
liquid effusions into both pleurae, which he considers, by pressing
the heart against the walls of the chest, assisted in the extension
of the friction sounds. My experience, however, leads me to con-
clude, that the friction sounds are not necessarily extended, even
though the heart be under extreme pressure. I shall presently
adduce two cases of empyema, one of the right, the other of the left
pleura, in which great eccentric displacement occurred. In the
last case, indeed, the heart, at the time it became affected with
pericarditis, was dislocated far to the right side, yet even under
this amount of pressure the friction signs remained confined accu-
rately to the heart in its new situation. In the case of empyema
of the right side the pressure was so great as to depress and alter
the form of the liver, and to cause dulness extending across the
median line ; in this case, too, the friction signs were completely
localized.

Finally, we have never observed that, even when rendered
more distinct by pressure with the hand, the friction sounds ex-
tended beyond their original situation.

Upon the whole, I incline to the opinion that extension of the
sounds in pericarditis is to be referred to the special character of
the sounds themselves rather than to any effect of internal pres-
sure.

The last source of modification is the existence of valvular

PERICARDITIS.

disease, either contemporaneous or previously existing. In certain
cases this combination may cause some obscurity in diagnosis, but
I believe that writers have over-estimated the amount of the diffi-
culty. If we take the case of a previously existing valvular disease,
the following circumstances will serve as means of diagnosis : —

First. The actual acoustic character of the sound.

Second. Its arising from a point comparatively deep-seated,
and where it is at its maximum.

Third. Its not being equably or nearly equably diffused over
the surface of the heart.

Fourth. Its greater extension over the thorax.

Fifth. Its frequent want of the double character, the first or
the second sound of the heart being often unattended with
murmur.

Sixth. Its being frequently transmitted along the aorta and
its primary branches.

Seventh. The absence of friction sensation communicated to
the hand.

On the last character it is to be observed, that the valvular
tremor, like the sound, has, in many cases, a point of greatest inten-
sity, and is not extensively diffused, as in pericarditis. Indeed, un-
less in some of the rare cases of varicose aneurism, the maximum
point of the tremor is generally determinable without difficulty.

There is, perhaps, a greater difficulty in settling the question
when the disease affects the mitral valve, leaving the aortic orifice
free ; for in this case we have no transmission of the murmur along
the vessels. A careful consideration, however, of all the pheno-
mena will, in almost every case of doubt, lead us to a correct con-
clusion.

I have already observed, that the signs of pericarditis must
have often been mistaken for those of diseased valves. But their
sudden supervention in a case where they had never before ex-
isted, the accompanying sign (when present) of the rubbing sen-
sation communicated to the hand, the rapid change of situation,
the equally rapid modification by treatment, and the occurrence
of the signs with both sounds of the heart, in a case which pre-
viously presented no evidence of organic disease, form a combi-
nation of circumstances which can hardly mislead.

VOL. i.

INFLAMMATION OF THE HEART.

But when it happens that, coincident with the attack of peri-
carditis, a diseased action is set up in the valves, the determination
of the latter may be difficult, during the continuance of the true
friction murmurs. If the valvular sign be, as it commonly is, a
bellows murmur, it may be completely masked by the loudness of
the friction sounds, and only become manifest on their cessation.
For some time, too, before these latter have wholly subsided, but
when they have lost much of their loudness and roughness, it may
be difficult to say how far the two sounds are intermingled. Yet
the determination of the question is of importance only as relating
to the prospects of the patient. It is a question of prognosis rather
than of treatment; and the case in question illustrates this impor-
tant maxim, that in acute affections, when the diagnosis of the
diseases of adjacent parts is difficult or impossible, it is often un-
necessary, so far as treatment is concerned*1.

The development of valvular murmur, in recent cases of peri-
carditis, does not appear to me to possess the value assigned to it
by Dr. Hope and Dr. Watson as an indirect sign of pericarditis.
I have never observed the valvular to precede the friction mur-
mur, though the signs are often found to co-existb ; and I believe
that in these cases the diagnosis of endo-pericarditis may be
made. Dr. Hope seems to have overrated the frequency of the
combination, or, to speak more correctly, has underrated the
occurrence of simple pericarditis, in which there is no valvulai
murmur developed, either during the acute stage of the disease
or even after its cure by adhesion. On the other hand, that the
cure of acute pericarditis is often unfortunately imperfect, inasmuch
as the patient recovers with an established valvular murmur, is
too true ; and though years may elapse before the valvular disease
produces its full effect in embarrassing the circulation, he has,
from the time of his apparent recovery, a slowly advancing, insi-
dious, and unconquerable disease.

We have, however, observed some cases in which a murmur

a ln two of the cases recorded by Dr. Mayne, no murmur preceded the attrition sounds,
although at the time of observation the pericardium was manifestly in a state of inflam-
mation. Increased action of the heart was the principal sign. See Dublin Journal of
Medical Science, First Series, vol. vii.

b Whether any effect of adhesion of the sac, by interfering with the free action of the
muscles, might for a time cause murmur, is worthy of inquiry.

PERICARDITIS.

with the first sound of the heart, though distinct for many days
after recovery from pericarditis, gradually subsided and did not
re-appear. Was this the result of retrocedence of valvular inflam-
mation, or was the murmur one of those sometimes attendant on a
weakened state of the heart ? The latter supposition appears most
probable.

It may be inquired, whether any assistance can be derived,
in the diagnosis of pericarditis, from studying the acoustic signs
which are proper to the muscular contraction of the heart, simply
considered. This is a subject on which new researches are re-
quired, yet I cannot but think that some important results would
follow from the investigation. It is to be determined whether
any sign, independent of the irregularity of the heart’s action,
could be discovered, which would indicate the extension of dis-
ease to the muscular structure ; whether the ringing sound of the
ventricular contractions may be taken as a proof of the first stages
of myocarditis ; whether any purely muscular murmurs are de-
veloped ; and lastly, whether, in the advanced stages of inflamma-
tion, the muscular sounds become weakened or destroyed.

With reference to the last point I can state, that I have ob-
served the disappearance of the first sound of the heart in cases of
severe pericarditis ; so that if we except the irregularity of action,
the signs closely resembled those of the softened or weakened
heart in typhus fever; and although the cause of this condition is
pathologically different, yet, physically considered, it is the same
in both diseases, and proceeds from the weakened state of the
muscular fibres, resulting in one from the effects of inflammation,
in the other from relaxation, with or without the interstitial ty-
phoid deposit.

Before noticing the signs derived from percussion, it will be
convenient to state, in separate propositions, the conclusions de-
rivable from what has been now advanced; and as it will not be
without value to ascertain what progress has been made in the
elucidation of the whole subject since the date of my memoir
(1834), I shall place first in order the eleven propositions which
contained the result of my researches up to that period, and then
continue the series, so as to embody whatever subsequent expe-
lience I may have had of the friction signs of pericarditis.

d 2

3(1

INFLAMMATION OF THE HEART.

1. That in cases of pericarditis with effusion of lymph, the
rubbing of the two roughened surfaces causes sounds perceptible
to the ear, and vibrations communicable to the hand, by which
the disease can be easily and surely recognised, even when all
other indications are absent.

2. That the more rough the state of the serous membrane, the
more distinct will these signs be.

3. That they accompany both sounds of the heart, but are most
distinct with the first sound.

4. That they are in general audible only over the region of
the heart.

5. That they present themselves with various modifications of
character, but sometimes resemble the sounds produced by exten-
sive valvular disease.

6. That they are most distinct when the region of the heart
continues with its natural sound on percussion, but that the ex-
istence of fluid does not necessarily imply their complete sub-
sidence.

7. That they may re-appear either after the absorption of fluid
from the sac of the pericardium, or the supervention of new in-
flammation.

8. That the sounds may continue when the sensation of rub-
bing is no longer perceptible by the hand.

9. That they are singularly and rapidly modified by direct
antiphlogistic treatment.

10. That by observing the progress and mutations of these
signs, we can trace the process of organization or of obliteration
of the pericardial cavity, judge of the effect of treatment, and
accurately ascertain the state of the pericardium.

11. That, hence, it must be admitted, that auscultation is of
direct utility in pericarditis, and that the diagnosis no longer rests
on negative signs11.

12. That the vital symptoms of acute pericarditis, with the
exception of pain, are to be referred more to irritation or excite-
ment of the muscular portions of the heart, than to the corres-
ponding states of its external or internal membrane.

* See Dublin Journal of Medical Science, First Series, vol. iv. (1834).

PERICARDITIS.

13. That acute pericarditis is often so latent as to be discover-
able only by physical signs.

14. That this latent form, however, may suddenly assume a
manifest and violent character.

15. That the cases of this disease may be divided into three
great classes.

a. Simple dry pericarditis, with little or no muscular

excitement.

b. Acute pericarditis with liquid effusion, and with, in

many cases, a greater amount of muscular excite-
ment.

c. Acute pericarditis with effusion, and with severe

symptoms of muscular suffering, as indicated, first,
by excitement, and secondly, by paralysis.

16. That death in pericarditis may be generally attributed to
syncope or pseudo-apoplexy, caused by paralysis of the heart.

17. That the effect of the pressure of the effused fluid on the
heart has been probably overrated.

18. That the weakness of the heart may proceed from simple
atony or paralysis, or result from true myocarditis.

19. That in the more violent forms of pericarditis there is
often a complication with other diseases, both local and general.

20. That the first stage of pericarditis may be observed with-
out the existence of any friction sign.

21. That this stage is of short duration, so that the want of
friction signs in the first stage cannot be adduced as an argument
against the utility of physical signs in pericarditis.

22. That the length of this period probably varies from six to
thirty-six hours.

23. That the absence of friction signs in the first stage is of
less importance than appears at first sight; for if the disease be
violent and dangerous, it is indicated by symptoms, and if it be
mild and simple, its discovery in the very first stage is of compa-
ratively little importance.

24. That the existence of air in the sac, whether originally
secreted (pneumo-pericarditis) or introduced by a fistulous open-
ing, modifies the friction sounds in a special manner, producing
cracklinsr, eureline, and metallic sounds, sometimes audible at a

O 7 O O O '

INFLAMMATION OF THE HEART.

great distance from the patient. This is, so far, confirmatory of
the suggestion of Laennec.

25. That in the first of these cases, on the absorption of the
air, the ordinary character of the friction signs may be produced.

26. That distention of the stomach with air may give a dis-
tinct metallic character to the friction sounds.

27. That the sounds most commonly heard over a large sur-
face of the chest are the leather-creak sound of Collin, and the
loud rasping sound proceeding from indurated lymph.

28. That lymph may be produced in the pericardium, of an
almost cartilaginous hardness, as a result of acute disease.

29. That the extension of the sounds seems more related to
their actual character than to the pressure exercised on the heart,
or the volume of the organ.

30. That, nevertheless, pressure exercised on the cardiac re-
gion is often followed by an increase of the loudness of the friction
sounds, and of the distinctness of the tactile signs.

31. That in cases of combination with pleurisy of the left lung,
not less than five attrition sounds may be produced. Of these
two are from the heart, two produced by the ascending and de-
scending motions of the lung, and one from the impulse of the
heart against the pleura.

32. That, consequently, a variety of rhythms of the friction
sound may be thus developed.

33. That enlargement of the heart does not necessarily imply
that the friction sounds will be heard beyond the space occupied
by the organ.

34. That although in certain stages of some cases of pericar-
ditis a difficulty may arise in determining the exact nature of the
sounds, as distinguished from valvular murmurs, yet that this diffi-
culty, which is only temporary, appears to have been overrated.

35. That we are to depend for accuracy in diagnosis on the
actual acoustic character of the signs; on their diffusion or con-
centration at a point of greatest intensity ; on their being superfi-
cial or deep-seated ; on their amount of extension over the thorax ;
their double or single character ; their transmission or non-trans-
mission along the course of the vessels ; on the presence and cha-
racter of the tactile signs; on their constancy or variability in

PERICARDITIS.

character and seat ; and on the effect of treatment in their modi-
fication.

36. That the diagnosis of an adherent pericardium can only
be made with certainty in cases where we have observed the phe-
nomena of effusion and organization of lymph.

37. That adhesion may co-exist with atrophy as well as hyper-
trophy of the heart, and lastly, may be found with a heart unal-
tered in its capacity or muscular condition11.

* See the works of Hope, Walshe, and Bartlie and Roger, where the principles of the
differential diagnosis are given. I announced most of these characters in my communi-
cations on Pericarditis, Dublin Journal of Medical Science, First Series, vols. iii. and iv.
(1833-1834).

I confess to a feeling of natural pride, when I find that my labours on the subject of
the diagnosis of pex*icarditis have elicited the testimony and approval of such authorities
as Dr. Forbes and Dr. Hope ; and I tbink that in transferring to these pages the recorded
sentiments of these observers, I may be fairly excused.

Dr. Forbes, after referring to the propositions at the conclusion of my paper, says : —
“ The facts so concisely announced in the preceding propositions are of such practical
importance, that I must recommend the attentive consideration of every one of them to
the reader. It is most gratifying to those who were the early and, by some, the suspected
advocates of auscultation, to find it gradually working its way to the high places of the
profession, and vindicating its true philosophical character by successive improvements
and discoveries, among the most valuable of which I do not hesitate to regard those of
Dr. Stokes, detailed in the present note.” See the translation of the work of Laennec by
Dr. Forbes, Art. Pericarditis.

In his classical work on Diseases of the Heart, Dr. Hope has the following remarks : —
“ The history of the discovery of the various murmurs of endo-pericarditis is as fol-
lows : — After the discovery of ‘ creaking of new leather’ by Collin, in 1824, Dr. Latham,
in 1826, discovered a bellows murmur with the first sound, as a sign of rheumatic peri-
carditis. He communicated this to me in the same year ; and I found, and published in
the first edition, in 1831, that the murmur accompanied not only rheumatic, but any
kind of pericarditis ; that it sometimes attended the second as well as the first sound ;
that it was referable, not to the pericardium, but to co-existent endocarditis, and that it
was the earliest and best sign of inflammation of the heart. Dr. Elliotson had, unknown
to me, published in the previous year, that the murmur was referable to endocarditis. I
can now distinctly recollect various cases in which I noticed that the murmurs were
1 creaking,’ ‘ anomalous,’ ‘ extraordinary ; ’ and I entertain no doubt that these were
attrition murmurs: I failed to discriminate them, because, during the last ten years, not
having had a fatal case of acute pericarditis, I have not had the opportunity of post-mor-
tem verification. Had Collin given a happier name than 1 bruit de cuir neuf' to attrition
murmurs, I have no doubt that they would have much sooner been recognised. Though
the honour of giving the first clue to this class of murmurs belongs to Collin, and though
Broussais, as will presently be shown, noticed the sound like rubbing of parchment, yet the
merit of satisfactorily unravelling the whole subject is, in my opinion, to' be awarded to
Dr. Stokes (Dublin Journal of Medical Scienec, First Series, vol. iv. Sept. 1833). Ap-

INFLAMMATION OF THE HEART.

SIGNS DERIVABLE FROM PERCUSSION.

We use percussion with advantage in every form and stage of
pericarditis. Its results are negative or positive. Negative when,
as in dry pericarditis, there is no alteration of the sound, and po-
sitive when the increase of liquid effusion extends the line of
dulness, or when by absorption the natural sound of the heart is
restored.

It has been supposed, that in carditis there is an extension of
dulness, not to be attributed to liquid effusion, but to the inflam-
matory turgescence of the heart. Such an occurrence is, at least,
doubtful, and we may safely assume, that the variations of sound in
pericarditis, depend on the actual amount of the effusion.

According to Hope, the presence of half a pint of fluid is suffi-
cient to cause a perceptible increase in the line of natural dulness ;
and the same author has observed, that as compared with the dul-
ness in hypertrophy, this dulness from effusion mounts higher up,
in the direction of the great vessels.

The effusion causing this dulness being almost always inflam-
matory, it happens that friction signs precede, and up to a certain
point co-exist with the extending dulness. They then commonly
cease for a time, to re-appear when, from absorption of the fluid,
the inflamed surfaces come into apposition. But there are cases
in which, though modified in intensity, the rubbing sounds con-
tinue through the whole period of effusion. They are compara-
tively feeble, and confined to the base of the heart, while the
dulness is extended, but are developed over a larger portion of the
organ, when the liquid effusion is removed. At this latter period,
the rubbing sensation communicated to the hand may or may not
be present.

The dulness, so far as it extends, is complete, and we do not
know any means by which, from its mere character, it can be dis-

parently without being aware of the researches of Dr. Stokes, Dr. Watson also published,
in the Medical Gazette, April 11, 1835, two cases of endo-pericarditis, in which he de-
scribes the to-and-fro sound of attrition, and perfectly distinguishes it from the co-exist-
ent valvular sound. M. Bouillaud does not appear to claim originality respecting the
attrition sounds, but states that he had observed bruit de snufflet in pericarditis at a period
when he was completely ignorant of the labours of Drs. Latham, Hope, and Stokes.”

PERICARDITIS.

tinguished from that of empyema or consolidation of the lung. It
is by the preceding and accompanying circumstances that its na-
ture is to be settled. By some it is objected, that the complica-
tions with disease of the lung or pleura act in lessening the value of
percussion in pericarditis. But this supposition is contradicted
by experience. The combination of pericardial effusions with such
affections is not common, at least in this country; nor, on the
other hand, are those cases of pericarditis of frequent occurrence
in which the effusion is so great as to simulate empyema. It is by
connecting the results of percussion with the preceding and ac-
companying stethoscopic signs, that their real value can be estab-
lished. If, for example, a dulness occurs within a short space of
time, unattended with signs of pneumonia or of pleurisy, but hav-
ing been preceded by friction signs referable to the pericardium,
no difficulty can arise in determining its nature. Again, pleuritic
dulness almost always appears first posteriorly, while pericarditic
dulness originates in the front of the chest. Now, although an em-
pyema may cause dulness of the front of the chest, and a pericar-
dial effusion dulness of the posterior portion, yet the following
considerations will enable us to avoid error.

An empyema often causes dulness of the anterior portions of
the chest. But this is, I believe, in all cases preceded by a loss
of sound posteriorly. The rule, then, is this, that in cases where
a doubt exists between a pleuritic and a pericarditic effusion, if we
find the postero-inferior portion of the side clear, we are to adopt
the latter supposition.

In both cases dulness anteriorly exists. In empyema the pos-
terior dulness is antecedent, while in those rare cases of very co-
pious effusion into the pericardium, sufficient to cause dulness
laterally and posteriorly, the anterior dulness is the first to occur.

If, then, we find an extending dulness anteriorly, stretching
from below upwards, not attributable to disease of the lung, and
coinciding with a clear sound in the infrascapular region, we may
make the diagnosis of pericardial effusion.

This dulness, in some cases, especially those where pericarditis
is associated with diffuse inflammation, or some of the essential
diseases, may be produced with great rapidity, and it may also dis-
appear or diminish within short spaces of time.

INFLAMMATION OF THE HEART.

I have not met with any of the cases of effusion so copious as
to simulate empyema. In the case communicated by Dr. Corrigan,
the distention of the pericardium reached to the first rib, and yet
no difficulty seems to have been felt in the diagnosis'1.

VISIBLE SIGNS OF EXCENTRIC PRESSURE.

The two most important observations on this subject with
which I am acquainted are those by Avenbrugger and Louis :
the first relating to the production of an epigastric tumour; and
the second to a dilatation of the side, analagous to that from em-
pyema.

Avenbrugger’s words are as follows: “ Scrobiculum cordis tu-
mor occupat, quem renitentia sua distingues facile a ventriculo
flatibus turgente.” This observation is confirmed by Corvisart, who
cites a case in which seven or eight pints of liquid existed in the
pericardium, causing not only obliteration of the natural hollow
of the epigastrium, but producing a large tumour in that situation.
This tumour appeared hard and resisting, and was occasioned by
the yielding of the diaphragm before the pressure of the confined
fluid. I have described a precisely analogous condition of the
right ala of the diaphragm from an extensive empyema.

* “ It may be objected,” says Louis, “ to the value of percussion, that pericarditis is
frequently complicated with pneumonia or pleuro-pneumonia, in which case it can be of
no utility, since it would be impossible to say whether dulness proceeded from an effusion
in the pericardium, or some other cause. The objection is a good one in cases of double
pleurisy or pleuro-pneumonia, or where the disease occurs on the left side, but when these
affections occur only on the right, percussion of the pnecordial region has the same value
as in simple pericarditis. Now, these cases are not very rare; out of seventeen cases of
pericarditis, complicated with pneumonia, recorded by Morgagni, Corvisart, and Bertin,
six are pleuro-pneumonia of the left side, five of double pleuro-pneumonia, and the re •
maining six of pneumonia at the right side, so that in a third of the complicated cases
percussion would have been of the greatest utility. But in twelve of the thirty-six ob-
servations with which we are now dealing, there existed no complication with pneumonia
or pleurisy, so that if we add these twelve observations to the preceding six, we have
eighteen cases out of thirty-six, in which percussion would give the most useful results.
“ It is not to be forgotten,” he adds, “ that I do not seek to place the results of percus-
sion before the other signs of pericarditis, but only to estimate the value of the method,
without which, no matter what may be the number and degree of the other symptoms,
the diagnosis of pericarditis cannot be considered as certain.” — liecherchcs Anatomico-Pa-
t/wlogiqut’s , p. 280. See also Dr. Law’s Pathological Observations, Dublin Journal of
Medical Science, First Series, vol. vii. (1835).

PERICARDITIS.

The next of these signs is that observed by Louis, namely, the
dilatation of the pracordial region, which only differs from that
in empyema by its remarkable circumscription. It was observed
but in a single case, and the tumour extended from the hollow of
the axilla to the edge of the false ribs ; anteriorly and superiorly it
ascended to within three inches of the clavicle. Over this tumour
there was no oedema of the integuments, but pressure caused pain ;
and, as might be expected, there was perfect dulness on percussion,
and absence of respiration over its whole extent. The sound of
percussion over the remainder of the chest was natural, but the
epigastrium and a portion of the left hypochondrium were dull.
These parts were painful to pressure, and slightly prominent.

This observation was made on the eighth day of disease ; the
case was a very protracted one, nearly three months having
elapsed before the patient’s death ; the pericardium contained a
pint and a half (French) of fluid, which had depressed the dia-
phragm ; the heart was somewhat diminished in size, and there was
no evidence of any malformation of the chest.

Although no opportunity has occurred to me of observing this
dilatation, yet I feel sure that it is not uncommon, and to this
opinion Louis himself inclines. Perhaps, as Dr. Walshe has re-
marked, from the pericardium being less in connexion with the
thoracic muscles than the pleura, dilatation of the side is not so
constantly or so soon produced by its inflammation.

Finally, Dr. Graves has recorded an example of extrusion of
the left lung upwards, in a case of pericarditis with extensive
effusion. The patient, a child aged 10, was attacked with symp-
toms of pericarditis eight days before admission, and presented
the usual signs of a pericardial effusion, with extensive dulness,
indistinctness of the heart’s sounds, and absence of murmur.
The dulness extended from an inch below the left clavicle to
the lowest part of the cardiac region, and to the middle and in-
ferior parts of the sternum. The left side of the chest appeared
fuller, particularly about the nipple, but measurement detected no
inequality. On the following day a swelling of the lower part of
the left side of the neck was evident, and on coughing a tumour
was brought into view. The sound on percussion in the scapular
region hud a tympanitic character. The pericardium was.found

INFLAMMATION OF THE HEART.

distended by serum to at least three times its natural size, and
covered with lymph. After remarking on the extrusion of the
left lung above the clavicle, Dr. Graves states his belief, that not-
withstanding the equality of the sides on measurement, the peri-
cardial region was really distended} and to this he attubutes the
increased resonance of the upper portion of the chest, on the prin-
ciples indicated by Dr. Williams, of increase of tension causing
augmented resonance11.

I have myself observed the displacement of the left lung to a
considerable height above the clavicle, in a case of pericardial
complicated with pleuritic effusion on the left side. In this case
the tumour, though increased by coughing, was present for several
days, and gave the pulmonary sound on percussion, with vesicular
murmur and wheezing rale. The patient recovered. The tumour
was so large as to produce during its continuance great deformity
in the neck.

Having now examined into the physical signs of pericarditis,
we proceed to consider its vital symptoms and history. Like
many other local diseases, it is found in various forms and degrees
of intensity, as shown by the amount of functional lesion, and the
sufferings of the patient. Practically we may divide cases of the
disease into three classes: —

1. Latent and trivial.

2. Latent and dangerous.

3. Manifest and dangerous.

The essential characters of the first of these classes are, loca-
lization, absence of essential disease, and lastly, a slight or feeble
inflammatory action. We owe to pathological anatomy the dis-
covery that almost every organ is liable to disease of this kind;
disease, difficult or impossible to be recognised during life, because
unattended by functional change, or any general disturbance.
Occasionally, as in some cases of serous inflammations, it is ac-
cidentally discovered by physical signs. In pericarditis, if we
admit that the milk spots are of an inflammatory origin, we must
allow that the disease has affected a vast number of persons, yet in
so mild a form, as not to excite suspicion at the time of its exist-

11 Clinical Medicine, vol. ii.

PERICARDITIS.

ence, nor to cause lesion in the function or structures of the heart.
But when the number of instances are recollected in which not
only a circumscribed spot, but even the whole pericardium has
been attacked by inflammation, as shown by the stethoscope, yet
without a symptom that would lead to a suspicion of the disease,
we cannot hesitate to admit, that pericarditis is one of the most fre-
quent of the unrecognised and often harmless diseases which affect
the human body.

But we would commit an error if we supposed that the want
of symptoms, and the feebleness of the physical signs, would jus-
tify us in considering the patient in a safe position. On the con-
trary, while any signs continue he must be carefully watched;
for, in certain cases, a sudden change occurs, and the disease is
converted from an apparently trivial and latent affection into a
more severe form.

If we now consider tlie second class of these cases, namely, those
which, though latent, are not without danger, we find that they
may be divided into the complicated and uncomplicated forms.
Of these, the first is, of course, the most important. We may have
complication, as in cases where other serous inflammations are co-
existing, such as pleurisy or peritonitis, when they occur as original
local diseases; and, again, as in cases where the complication is
with a general or essential disease, such as rheumatic fever. To
this form it might be better to give the name of secondary latent
pericarditis.

In latent pericarditis the disease is only discernible by physi-
cal examination, and as there is seldom any change beyond the
effusion of lymph, the indications are limited to the tactile and
acoustic friction signs.

It is this variety which is so often met with in rheumatism ;
and although in this disease the more severe forms may arise with
or without endocarditis, yet the occurrence of the latent form is
sufficiently common to justify the practical rule, that in any case
of acute articular rheumatism we cannot be certain that the heart
is safe unless by the careful employment of the stethoscope. So
true is this, that it becomes absolutely necessary, if we seek to
avoid being surprised by an attack of pericarditis, that yre should

INFLAMMATION OF T

examine our rheumatic patients from day to day. even though
they present no symptoms of cardiac disease.

This liability to pericarditis, however, is less allied to the more
occurrence of rheumatic inflammation, considered as a disease of
tissue, than to the essential state which we call rheumatic fever.
It will be found that the liability to all the forms of carditis in
rheumatism is in proportion to the severity and obstinacy ol this
fever. Indeed, in the apyroxial east's, even of acute arthritis, the
pericardium commonly escapes; and in that remarkable disease
of chronic-rheumatic arthritis, on which so much light has been
thrown by the researches of Or. Adams and Professor Smith, it
rarely happens that the heart sutlers, at least from acute disease.

I have repeatedly observed this disease to affect a large number
of the joints in a short space of time, and yet have found the cir-
culation unaffected, and the heart, tip to the last periods ot life,
free from any morbid acoustic sign.

As bearing on tbis point, and especially as illustrative et the
necessity of considering rheumatic fever as an essential disease,
not necessarily co-existing with arthritis. I may refer to two east's,
one of which occurred to me in 1 800 ; the other is given by Dr.
Graves in bis Clinical Medicine. In both, pericarditis preceded
the inflammation of the joints, in my case by an interval ol ten
davs, and in that by Dr. Graves, by live days. In the former ease
the symptoms were prsecordial pain and oppression, with severe
dyspnoea, and a cough which greatly aggravated the pain. The
patient had also symptoms and signs of pneumonia ol the right
lumr. It was not until the eleventh day that arthritis appeared,
when the articulations of the lower extremities became swollen
and painful, and this condition soon extended to the left arm.
This patient sank with symptoms of pneumonia and pericarditis.
I11 the case by Dr. Graves the symptoms and physical signs of
pericarditis preceded the articular inflammation, and it was not
until all siuns and symptoms of pericarditis had subsided, that the
patient was attacked with acute arthritis in the knees, shoulders,
wrists, and ankles.

The disease ran the usual course of severe articular rheuma-
tism. and lasted for ten or twelve days, during which time the

PERICARDITIS.

heart, which was daily examined, exhibited no sign of disease.
The treatment consisted in the exhibition of opium in large doses,
as recommended by Dr. Corrigan, and succeeded admirably, none
of the deleterious effects of the drug having been produced®.

To discuss the general pathology of rheumatism would be
foreign to the objects of this work. With reference, however, to
its connection with pericarditis, we may adopt the following con-
clusions : —

1. That though the combination of pericarditis with acute
articular rheumatism is common, yet that the disease of the heart
is more closely related to the rheumatic fever than to the inflam-
mation of the joints.

2. That the liability to pericarditis is in direct proportion to
the violence and duration of the fever.

3. That in the apyrexial cases of acute arthritis, the liability
to cardiac inflammation is but slight.

4. That pericarditis may be developed at any period of the
disease, and even precede the arthritis.

5. That every variety and degree of pericarditis may occur in
connexion with acute rheumatism, from the simple, dry, latent
pericarditis, to the worst forms, combined with inflammation of
the endocardium and muscular structure.

Although, as we might expect, the complication of acute rheu-
matism with pericarditis occurs under a variety of forms, yet three
principal divisions of such cases may be made by the clinical ob-
server. In the first, the disease, as regards symptoms, is truly
latent, so that its discovery, which is only attainable by physical
examination, is often accidental. In the second form, this latent
disease may become manifest, and be indicated by a new train of
symptoms, which at once draw attention to the internal disease,

a On this subject Dr. Latham has the following important observations : “ But who

shall say that endocarditis and pericarditis are not equally essential to it with inflammation
of the joints, and that both are not equally derived from the attendant fever ? . . .

And I have seen a few cases (but very few) in which the inflammation of the heart has
seemed to precede the inflammation of the joints. There has been fever, and with it pal-
pitation and prsecordial pain. Thus far the disease has been a puzzle. In a day or two
the joints have become inflamed, and shown the disease to be rheumatism ; and the endo-
cardial murmur has been added to the palpitation and to the prsecordial pain, and shown
the sure existence of endocarditis from the beginning.” Latham, pp. 229, 232.

INFLAMMATION OF THE HEART.

and it will then be found that the pericarditis has changed from
the simple plastic form to a more severe affection, accompanied
with copious effusion. This sudden change of dry, latent peri-
carditis into the more important forms of disease is an accident
which must always excite great alarm.

In the last form the invasion of the pericarditis is attended by
distinct symptoms of cardiac suffering, and these, as Dr. Mayne
has shown, may exist for one or two days before the appearance
of any tactile or acoustic sign of the disease. Of the local symp-
toms, pain and weight in the region of the heart, with an in-
creased impulse of the organ, are not uncommon. The pulse
may, in some cases, be wiry and regular, while in others, irregu-
larity of the heart’s action is one of the first symptoms. It is impor-
tant to notice this, as we may commonly connect the idea of irre-
gularity of the pulse with the weakened state of the organ in the
advanced stages of the disease. Evidences of irritation of con-
tiguous organs are often seen. The left pleura may present symp-
toms of disease, bronchitic or pneumonic rales may appear in the
left lung, while vomiting and epigastric tenderness indicate that
the stomach sympathizes with the diseased organ, or itself par-
takes in the irritation. In some cases the invasion of these symp-
toms is attended with a mitigation of the arthritis, but this is by
no means usual. I have been more than once led to suspect pericar-
ditis from a sudden increase of fever, without corresponding in-
crease of tumefaction in the joints. The countenance is anxious,
with a sense of sinking about the heart, and apprehension of death.

In most cases the symptoms will be found attended by physi-
cal signs of attrition, of effusion, or both, varying according to the
pathological state of the pericardium. The occurrence of bellows
murmur is inconstant, and seems to indicate a complication with
endocarditis.

We may now consider the general symptoms of the more
severe forms of pericarditis, occurring independently of any rheu-
matic complication. On this part of the subject our best autho-
rity is Louis, who has accurately investigated the symptoms of
this disease51.

a Rccherchcs Anatomico-Pathologiques, Art. Pericarditv.

PERICARDITIS.

The system, so long adopted by writers on medicine, of speci-
fying a group of symptoms as indicative of a particular disease,
has led to errors in diagnosis and practice. Hence, in attempting
to describe or enumerate the symptoms of pericarditis, it must
be understood that none of them are constant ; and, further, that
there may be great variation in the mode of succession of the
phenomena in different cases. The first and most important
symptom is pain in the region of the heart, frequently attended
with a feeling of constriction or weight about the affected organ.
This pain is generally less acute than that in pleurisy, but it is
sometimes agonizing. It may also be felt in the epigastric and in-
terscapular regions. Closely connected with this symptom is that
of tenderness on pressure, with or without oedema of the integu-
ments, in the cardiac and epigastric regions. In some cases the
pain is intense and lacerating, and referred at first to the middle
sternal region, attended with a most painful sensation of constric-
tion of the chest.

Similar to the pain in pleurisy in its intensity, and in some
cases in its seat, the pain of pericarditis has been occasionally
observed to differ from that of pleurisy in this, that it is not aug-
mented by a deep inspiration nor by change of position. It has
been observed also to resemble that of angina pectoris in a remark-
able degree. Thus, in a case by Andral the patient was subject
to dreadful exacerbations of pain extending through the entire of
the leftside, accompanied by numbness of the left arm alternating
with extreme pain. On three occasions the respiration became
difficult, the pulsations of the heart tumultuous, the pulse imper-
ceptible, and the surface of an icy coldness. On the subsidence
of the paroxysm the heart’s action would again become regular.
In this case dissection discovered abundant concretions of coagu-
lable lymph in the pericardium, and the sac itself was distended
by a large quantity of bloody fluida.

Pain, however, is frequently absent, or the patient complains
only of uneasy sensations about the heart ; and this may occur
even when sudden and violent symptoms of another kind attend
the invasion of the disease. Generally it may be stated, that the

* Clinique Medicate, vol. i., Obs. Hi., p. 15.

VOL. I.

INFLAMMATION OF THE HEART.

absence of pain is more likely to be met with in the complicated
than in the simple cases, and the complication may either be with
an essential disease, or some local affection.

We are not yet fully informed as to the nature of the epigastric
tenderness in this disease. Dr. Mayne observes that this symp-
tom is generally very characteristic, and that it may be looked
on as the most unequivocal general symptom of the affection.
Out of eleven cases observed by him it occurred in ten, and in
five formed the principal source of the patients’ suffering. It did
not appear peculiar to any one period of the complaint. He ob-
served that it was best marked when pressure was directed up-
wards and towards the pericardium, and that it was more circum-
scribed than the tenderness resulting from abdominal disease.
Without, however, undervaluing these observations, we must not
forget that in acute pleurisy of the left side, the epigastrium is
often tender; and also, that from the rarity of acute gastritis we
have seldom an opportunity of comparing the symptoms of that
disease with those of pericarditis, which affection, so far as ten-
derness is concerned, may simulate inflammation of the stomach.

The next most important symptom is the difficulty of breath-
ing, which is often attended by high and accelerated respiration.
This latter character, however, may exist without the patient
complaining of any dyspnoea. Louis attaches but little value to
the oppression of respiration as a sign of pericarditis, although he
admits that dyspnoea to a greater or less degree existed in all the
cases which he has analyzed. He observes, however, that the
symptom is of importance if it has supervened suddenly, and that
no evidence of acute disease of the lung can be found. The same
observation has been subsequently made by Dr. Mayne. Dr.
Hope dwells on the dyspnoea in connexion with a constrained
position, deviation from which produces a feeling of suffocation.

If with reference to dyspnoea we compare the diseases ofpleu-
ritis and pericarditis, the following difference may be noted,
namely, that in pericarditis the tolerance of copious effusion is
less often observed than in acute empyema. Indeed, in the latter
affection it frequently happens, that after a certain period, not
only the dyspnoea, but the acceleration of breathing disappears,
so that the respiration is perfectly tranquil, at least while the

PERICARDITIS.

patient is at rest. Such a condition, however, is rarely, if ever
observed in copious pericardial effusions, and this can be easily
understood if we consider the anatomical .and physiological rela-
tions of the two diseases. In pleurisy but one-half of a double
organ, as it were, is engaged, the opposite half remaining free to
act ; and the compressed lung may for a time be dispensed with.
But in pericarditis we have not only the engagement of the entire
organ by inflammation, but also its general compression, and iu
most cases a weakening or semi-paralysis of the muscle. Hence
it is that although the subsidence of dyspnoea is often observed
in empyema, even with copious effusion, it is so rarely met with
in the analogous case of pericarditis.

Great stress has been laid on the character of the pulse in this
disease, yet clinical experience establishes that no special condi-
tion of pulse can be described as belonging" to any ^one form or
stage -of the affection. The following conditions may be met with :

1. Pulse small, rapid, and irregular at the onset of the disease,
before the development of the ordinary physical signs.

2. The pulse becoming singularly slow at the very commence-
ment of the disease3.

3. The pulse unaffected, except by the usual influence of fever.
Under these circumstances it may be perfectly equal and regular.
This is commonly seen in rheumatic fever with dry pericarditis.

4. Pulse regular, rapid, with a remarkable hardness.

5. Pulse regular, rapid, and feeble, while the action of the
heart is excited.

6. Irregularity, inequality, and feebleness of the pidso, with a
weakened action of the heart.

7. The same condition of pulse, with violent action of the
heart.

8. The pulse may present alternations of regularity and irre-
gularity.

9. Apparent suspension or obliteration of the pulse, succeeded
by its re-appearance after a certain period.

On the symptoms of irregularity and intermission of the pulse,
distention of the jugular veins, violet hue of the face, and coldness

“ We owe Ais and the preceding observation to Dr. Graves. See his “ Observations
on Pericarditis,” Clinical Medicine, 1843, p. 9IG.

E 2

INFLAMMATION OF THE HEART.

and oedema of the lower extremities, as occurring in the last
stages, we need not dwell at any length. With respect to the
first ofthese symptoms, however, it is to be remarked, that although
Dr. Graves has observed it before any direct sign of pericarditis
had occurred, yet in general we may hold it to be indicative of
an advanced stage of the affection, when the heart is weakened, or
suffering from inflammation of its muscles or lining membrane.

There is a symptom in this disease referrible to the arterial
system, which, though of great value, has been unnoticed, namely,
an increased action of the cervical vessels. As to its actual fre-
quency I cannot speak positively, but I have observed it in two
remarkable cases, one of which will be given when we speak of
the treatment of pericarditis. The patient was an adult. The
second case was one of well-marked endo-pericarditis, occurring
in a boy under ten years of age. When this patient was first
admitted he was in a state of collapse: the surface was pale, and
the radial pulse extremely feeble, yet so violent was the action
of the arteries of the neck, that it was visible at a distance, and
drew immediate attention to the case. The physical signs were
at first a double bellows murmur at the base of the heart, but on
the fifth day a creaking friction sound, feeble with the first, but
distinct with the second sound, could be heard at the apex. In a
a short time the friction signs became general, assuming their
ordinary character, and still attended with valvular murmur. Li-
quid effusion now took place, while the increased action of the
cervical vessels continued. At this period we observed that the
friction sounds were most distinct when the patient sat up. This
boy finally recovered, the disease having continued about eighteen
days. Towards the close of the case the friction signs assumed a
musical character, and were most distinct with the first sound.

In both these cases there was valvular murmur, and it is worthy
of inquiry whether this increased action of the carotids may prove
available in determining the presence or absence of endocarditis
in such cases. But it may be laid down, that if the symptom be
recent, and the constitutional state indicative of irritation or in-
flammation, this visible pulsation in the arteries of the neck, while
the remaining vessels act feebly, should lead us to suspect some
form of carditis.

PERICARDITIS.

Separately considered, this symptom, so far as I know, is met
with in but four cases. It is noticed by Sir Astley Cooper as oc-
curring in concussion of the brain, becoming evident when the
patient sits up, and being then attended with increase in the
frequency of the pulse®. It is met with in the earlier stages of
permanent patency of the aortic valves, at which period it may
be confined to the cervical vessels. We observe it, in the third
place, in a curious and special form of chronic disease, which shall
be presently described in full, attended with palpitation of the
heart, increased action of the cervical arteries, and enlargement of
the thyroid gland and the eyeballs. The fourth case is that just
now specified, and hence, especially when the question of time is
considered, the differential diagnosis will present no difficulty.

The risus sardonicus, contraction of the features, faintness,
paleness, failure of animal heat, continued jactitation, insupport-
able distress and alarm, cold perspiration, and finally, from ob-
struction of the circulation, intumescence and lividity of the face
and extremities, sometimes arising within the last twelve hours
of life, are noticed by Dr. Hope as the most important symptoms
of the disease in an extreme degree. To these he adds delirium
and convulsions in the last stage.

Among the rarer symptoms in pericarditis authors have no-
ticed the occurrence of maniacal excitement, sudden dissolution
of the eye, and lastly, dysphagia. The connexion of the two first
of these conditions with pericarditis is doubtful, but the occur-
rence of dysphagia is, perhaps, more easily understood. Testa’’

a See Sir Astley Cooper’s Lectures on Surgery. The symptom in question is given
as diagnostic between compression and concussion of the brain. An increased pulsation
of the carotids, analogous to that of the radial artery in whitlow, and, as I have observed
in another place (see Researches on the Diagnosis of Aneurism, Dublin Journal of Medi-
cal Science, First Series, vol. v.), to those of the abdominal aorta in gastroenteric fever,
may be met with in cerebritis, but such a case could not be confounded -with carditis.

b Testa’s work, Delle Malattie del Cuore, was published in Bologna, in 1811, and dedi-
cated to the Viceroy of Italy, Prince Eugene Beauharnois. The style of the author is
extremely diffuse, but it is a work of great research, and contains many original observa-
tions, which, independently of their value as cases of cardiac diseases, are of importance
to the student of this country who seeks to acquire an extended view of these affec-
tions as they occur in a warm climate and among another race of men, I published
some extracts from this work, in an English dress, in 1839, with reference to those
cases of carditis which simulate affections of the throat (see Dublin Journal of Medical

INFLAMMATION OF THE HEART.

has given some cases bearing on this point, which are worthy of
careful study.

In the first case a man was attacked with high fever, dyspha-
gia, and great difficulty of opening the mouth. Treatment had
no effect on the symptoms till the sixth day, when the pulse
moderated, but the dysphagia and pain in the throat remained.
Two days after this, appeared a swelling of the right parotid
region, which rapidly subsided. He died on the tenth day.
The fauces presented not the slightest trace of inflammation; the
pericardium was thickened and hardened, and the sac filled with
foetid sanies in great quantity. The heart showed marks of se-
vere inflammation, both of its membranes and muscular structure,
and the ventricles were lined with lymph. The diaphragm, liver,
and upper portions of the stomach were inflamed, as were all the
vessels, venous as well as arterial, in the vicinity of the heart.
There was a slight degree of pleurisy.

In the second case, a woman long subject to a quartan fever,
followed, after its cure by bark, with violent tremors of the lower
extremities, was attacked by rigors, succeeded by intense heat and
severe pain in the fauces, and the greatest difficulty in swallowing.
On the fourth day she was conveyed to hospital ; her face was
deep red, her parotids swollen, and the tonsils of a bright red
colour. Respiration was difficult, and similar to that of persons
affected with angina ; her voice was low and feeble ; there was
no cough, but no substance, solid or liquid, could be swallowed.
The diagnosis was made of angina pharyngea, with some laryn-
gitis. During the last two days she had alternations of coma and
delirium, and during the latter she swallowed with less difficulty ;
the pulse was small and tremulous. She died on the seventh

<%•

' This case was a combination of severe pericarditis with pleu-
risy. The pericardium was thickened, and contained a great
quantity of whitish purulent fluid; the heart had likewise suf-

Scicnce, First Series, vol. xiv.) In reference to these cases Testa observes: “ Nessuno
per altro, ch’io sappia, a fatto finora distinta menzione de^ sintomi anginosi, li quali non
solo si uniscono ai segni proprii del cuore infiammato, ma bensi li nascondono quasi
affatto sotto il solo apparecchio anginoso.” — Yol. iii. p. 106. The chapter containing
these cases is headed “ Dei Pericarditici e Carditiei Anginosi.”

PERICARDITIS.

forcd from carditis. Two more cases of dysphagia in connexion
with disease of the heart and pericardium are given by the same
author, the symptoms in one being a severe smarting in the oeso-
phagus whenever the patient was tempted to swallow even a
mouthful of water. Neither in the internal nor external fauces
could any alteration be found. These symptoms, attended by
fever and difficulty of breathing, occasional delirium, and an intole-
rable sensation of burning heat in the thorax, extending from be-
low the xiphoid cartilage to the fauces, continued up to the pe-
riod of death, which took place about the seventh day. The pulse
was small, rapid, occasionally intermitting, and the patient, an
adult male, was constantly exposing liis chest, being unable to
bear even the lightest covering. Tie was extremely restless, and
troubled with spectral illusions. False membranes were found on
the pleura, and the sac of the pericardium contained a great quan-
tity of thin sanies ; the heart, somewhat hypertrophied, was ul-
cerated on its surface. Marks of inflammation were found on the
diaphragm and in the liver, which was enlarged.

The last case is an example of pericarditis with serous effu-
sion, in which the symptoms were fever, a deep burning pain in
the chest and fauces, with dyspnoea, pain in the left arm, and a
soft, irregular pulse.

I have observed dysphagia as a symptom in thoracic inflam-
mations, and its accompanying phenomena seemed to prove that
it was less the result of any mechanical condition, such as pressure
on the oesophagus, than of some excited irritability either of that
tube or of parts immediately in contact with it.

A woman, aged upwards of 60, of an extremely, spare habit,
was attacked with symptoms of acute lumbago after exposure to
a draught of cold air. She remained for three or four days with-
out paying attention to these symptoms, when the pain suddenly
left the loins and ascended to the interscapular region. When I
saw her, the breathing was hurried ; the pulse small and wiry ;
and she complained of an extraordinary sensation upon attempt-
ing to swallow. As the mouthful of food or drink passed down
a few inches below the pharynx it excited a feeling of tearing
or burning through the remainder of the passage, which im-
mediately subsided on the ingesta reaching the stomach. There

INFLAMMATION OF THE HEART.

was no regurgitation, but her sufferings from the dysphagia were
extreme.

On examination I found the lower portion of the left side
sounding dull on percussion, with well-marked ajgophony at the
root of the lung, extending laterally for two or three inches. The
action of the heart was rapid, but not irregular, nor were any of
the direct signs of pericarditis present.

On the next day the heart was evidently displaced, and pul-
sated strongly under and to the right of the sternum, while it was
scarcely perceptible in its natural situation. In the course of this
case the action of the heart became very irregular, but no other
symptom of disease of the organ was manifested. After several
relapses of the pleuritis, the effusion was absorbed ; but on each
exacerbation the dysphagia became greatly aggravated, and was
always relieved by the application of leeches over the affected
portion of the left side. After her recovery from the pleuritis
the irregularity of the heart continued.

In two cases of pneumonia I have observed symptoms some-
what allied to those described by Testa; I have known aphonia,
without any other sign of laryngeal disease, to set in and sub-
side with an extensive inflammation of the left lung. The case
was that of a gentleman of full habit, who was attended by Dr.
Graves and myself. The hepatization resolved with extreme
slowness, but as soon as the side had recovered its sonoriety, the
aphonia disappeared. This was a most insidious case.

In a young man attacked with pericarditis the voice under-
went a great variety of changes of tone, and was not restored for
several weeks, when all symptoms and signs of pericarditis had
subsided. In this case, the liquid effusion was never very consi-
derable. The phenomena were slight dulness, with various mo-
difications of the rubbing sounds.

The foregoing facts all seem to prove that the symptom in
question, however produced, is less a mechanical than a vital ef-
fect. It occurs in the earlier, sometimes in the very first periods
of the case, and at a time when but little distention of the peri-
cardium has occurred. It may disappear in the more advanced
periods, and may be accompanied with phenomena indicating in-
terference with the functions of organs placed out of the reach of

PERICARDITIS.

pressure. Finally, when we consider its rarity in hydro-pericar-
dium, and in cases of empyema with great excentric displacement,
we must, I think, adopt the above-mentioned view of this curious
symptom.

I have already alluded to a case of sudden pleuritic and peri-
cardial effusion, in which the singular phenomenon occurred of
the thrusting upwards of the lung, so as to form a very large tumour
above the clavicle. This tumour had a puffy, elastic feel, and the
stethoscope detected evident vesicular murmur over its surface.
The disease was subdued by active treatment, and in a few days
the tumour disappeared. Here the left lung was suddenly com-
pressed by the double effusion, and yet no dysphagia was ob-
served11.

But with reference to the cases from Testa, this question
arises: were they examples of primary disease, or in reality in-
stances of diffuse inflammation with or without phlebitis, and in-
ducing the pyogenic state ? There are strong grounds for believing

“ In the works which I possess on diseases of the heart (with the exception of Testa),
I have not been able to find any notice of dysphagia as a symptom of inflammation of
the pericardium or pleura. I have examined carefully the works of Senac, Corvisart,
Bertin, Laennec, Bouillaud, Hope, and Andral. Testa alludes to the case of the wife of
Polemarchus, recorded in the fifth book of the Epidemics, but i consider it as scarcely
one in point. That of the courier in Morgagni is more important, and I shall not apolo-
gise for introducing it.

“ Vir erat annorum amplius quadraginta, qui Foro Cornelii Bononiam identidem
ventitabat pedes, res traditas hue illinc, et vicissim bine illuc ferens. Is cum saipe vel
ab itinere calens, biberet, postremo praisertim tempore quo assidue sitiebat, rbeumate ad
fauces gravi, et febre correptus, in Nosocomium admissus est. Mox ibi de faucibus non
amplius conquestus, suum in ventre morbum omnem essedicebat; nulla tamen de re que-
rebatur magis, quara de Spina: ad lumbos dolore, quo ea sibi media dissecari videbatur.
Erant propterea qui intestinorum inflannnatione laborare hominem, crederent : Valsalva
autem in thorace earn esse, suspicabatur. Erat autem pulsus debilis, humilisque; sed
qui tamen ligatus, ut ajunt, videretur. Surgere, quasi abiturus, sa:pe voluit. Per luce
intra tertium, an quartum ex quo in Nosocomium venerat, diem confectus est. Venter
nihil habuit quod secundum naturam non esset. In Thorace autem ab altera potissimum
parte humor stagnabat, in quo frusta natabant, quasi membranularum albissimarum ; ut
nihil magis referret, quara serum vaccinum, particulas retinens casei sccundarii. Pleura:
vasa magis quam solent, rubebant, nec multo id tamen. Pericardium terofuit qdeo
distentum , ut viv compunctum , aqua, ejus qua erat plenissimum , tenue quasi filum ad
non moilicum altitudinem ejaculaverit. Cordis niucro plus ;equo rubens, leviter intiam-
matus fuisse videbatur.” — Lib. ii. De Morbis Thoracis, Epist. Anat. Med. jevi. Art. -10.

INFLAMMATION OF THE HEART.

that such was their real character, and that the pericardial disease
was but one of a group of secondary lesions.' Let us remember
the occurrence of parotid swellings, of the foetid, sanious, and pu-
rulent effusion into the pericardium, the evidences of inflamma-
tion in the diaphragm, pleura, stomach, and liver, to say nothing
of the great vessels in the vicinity of the heart ; and lastly, the
symptoms of nervous disturbance, and we cannot but suppose
that these cases were of a phlebitic nature.

Taking this view of the matter, it may be asked whether the
dysphagia might not have proceeded from an inflamed condition
of the great network of veins which ramify in the retro-pharyngeal
cellular structure. Professor Smith has observed, that in many
cases of diffuse inflammation these vessels are so much affected as
to cause suppuration throughout the whole of this loose reticular
tissue, from the pharynx down into the mediastinum, and that
this condition may exist without our ever being able to discover
any tumour in the pharynx, although dysphagia and other symp-
toms of angina are presents

Among the rarer symptoms of, or rather the accidents con-
nected with this disease, are we to place the sudden destruction of
the eye, as described by Corvisart? This author gives a case
of pericarditis in which not less than two pints of sero-purulent
fluid were effused, while the heart was covered with a thick al-
buminous layer. The disease was singularly uncomplicated, and
had apparently resulted from a blow on the cardiac region. The
general symptoms presented nothing remarkable except the spon-
taneous and almost sudden dissolution of the right eye, without
any preceding or accompanying inflammation. At the time of
this occurrence the patient was in a state of great prostration. In
another case of pericarditis, which terminated in adhesion, the
right eye became eccliymosed and inflamed during an access of
cardiac suffering, but no dissolution of the organ is reported to

a See an important paper on the subject of abscesses posterior to the pharynx by
the late Mr. Carmichael. (Transactions of the Association of the College of Physicians
of Ireland, vol. iii.) Also, the Elements of the Practice of Medicine, by Drs. Bright and
Addison; and a Memoir on Pharyngeal Abscesses, by Mr. Fleming. (Dublin Journal of
Medical Science, First Series, vol. xvii., 1840.)

PERICARDITIS.

have taken place. In his first case the most careful examination
failed to detect any cerebral disease, and the sudden dissolution ol
the eye remains an unexplained fact.

Corvisart refers to Testa for examples of loss of vision in con-
nexion with disease of the heart; but the cases in question have
nothing in common with the instance given by the French patho-
logist. One of these cases appears to have been an example of
amaurosis ; others of superficial or deep-seated inflammation, and
there is nothing to lead to the belief that the injury of vision was
induced by disease of the heart.

It is more than doubtful that the sudden dissolution of the
eye, as noticed by Corvisart, is to be considered as depending on
carditis, or any form of disease of the heart: the eye suppurated,
and gave way without previous inflammation11. Such an acci-
dent, resulting from disease of the heart, has never, so far as I
have seen, been observed in this country ; but that it occasionally
occurs in cases of purulent phlebitis is certain. In this condition,
and without the slightest previous distress, as referred to the eye,
the patient sometimes becomes suddenly blind of one or of both
eyes. Within a short time pus can be detected in the chambers
of the organ, and should the patient survive sufficiently long, the
coverings may give way, and collapse of the eye-ball follow from
the simultaneous evacuation of the humours and purulent secre-
tion. The history of Corvisart’s case seems to bear out the view
that some typhoid condition of the system existed, and it is re-
markable that not less than sixteen days elapsed between the
infliction of the blow and the appearance of fever and oppression
of the chest.

We cannot, then, as I conceive, admit the sudden dissolution
of the eye as one of the symptoms of pericarditis. In the present
state of our knowledge it is only met with in phlebitic and other
analogous forms of inflammation.

We shall presently have to examine a special form of disease
of the heart, which is attended with a peculiar but very different
condition of the eye.

Having now considered the signs and symptoms of pericar-

* See the work of Corvisart, p. 17.

INFLAMMATION OF THE HEART.

ditis, we may, with advantage, study some examples of the dis-
ease.

Case I. — Acute dry Pericarditis, following the disappearance of a

cutaneous disease ; production of the Leather-creak Sound within

a short time before death.

A hoy, aged five years, had been cured of a cutaneous disease,
the nature of which was not ascertained. In a few days he became
ill, with symptoms of inflammatory fever; he had thirst, occa-
sional vomiting, short cough, hurried breathing, and orthopnoea;
the left side of the abdomen was full and tender, and he com-
plained of pain, referred to the belly. When I first saw him
he was sitting in bed, his legs drawn up, and with hurried, high,
and laborious respiration. The lips were livid, the face cedema-
tous, and the jugular veins distended; pulse 130, small, jerking,
but regular. The impulse of the heart was violent, with a distinct
rubbing sensation communicated to the hand ; a very loud friction
sound attended both sounds of the heart, and was heard to the
right of the sternum, under the clavicles, and along the spine.
In the latter situations, however, it had lost much of its rough-
ness, and approached to the bellows murmur. The sound on per-
cussion over the heart was dull to an unusual extent, and the res-
piratory murmur everywhere puerile and pure, with the exception
of a slight and fugacious bronchial rale. He died on the third
day after admission into hospital. On the day before death the
jugular veins pulsated, the abdominal tenderness had greatly in-
creased, and the friction sounds assumed the character of the “ bruit
de cuir neuf" of Collin.

On dissection, a general hypertrophy of the heart was dis-
covered; the pericardium was thickly covered on both surfaces
with a reticulated layer of reddish-coloured lymph ; no adhesion
had taken place, nor was there any liquid effusion into the sac;
tire mitral and aortic valves were slightly thickened, and some-
what opaque, but otherwise healthy. Circumstances did not per-
mit examination of the remaining viscera.

The occurrence of a dry pericarditis attended with such vio-
lent symptoms as were observed in this case is worthy of note.
It is rare to meet this form of the disease unless as a mild affec-

PERICARDITIS.

tion, and it is probable that to the previous existence of disease of
the heart we are to attribute the great virulence of the attack.
We shall just now examine another case, in which a dry pericar-
ditis co-existed with hypertrophy, and in which also the symptoms
were unusually violent. It may be laid down, that where we
have considerable dulness. over the heart, with a friction sound
extending over a large portion of the chest — a friction sound
which does not diminish, as where liquid is effused, but which,
as in the case now before us, actually increases in intensity with
the advance of disease — we may determine that the case is one of
dry pericarditis engaging an hypertrophied hearta.

Case II. — Acute dty Pericarditis with Hypertrophy and Dilatation

of the Heart.

A man, aged 20, after recovering from an attack which re-
sembled gastric fever, but was attended with severe pain in the

a Referring to Dr. Graves’s observations on tbe extension of the sounds in pericar-
ditis, it will be remembered that he dwells on the co-existence of an enlarged heart as an
important cause of the occurrence. I have already expressed my conviction that the ex-
tension of the sounds has more to do with their nature than the amount of surface of
the heart from whence they proceed. I did, however, in my observations on this case,
published in 1834, suggest that the enlargement of the heart might be a cause of exten-
sion of sounds. My words were as follow : “ The dulness of the region of the heart was
satisfactorily accounted for by the great hypertrophy of the organ ; a circumstance which,
taken in connexion with the excitement of the heart and the age of the patient, may ex-
plain the unusual extent to which the stethoscopic phenomena of pericarditis were audi-
ble.”— Researches on the Diagnosis of Pericarditis, Dublin Journal of Medical Science,
First Series, vol. iv., 1834.

The best and most comprehensive account of pericarditis as occurring in infancy and
childhood is to be found in the work of Dr. Churchill on the Diseases of Children. It does
not appear that when the affection is met with in young children there is any special
character attending the disease. Its symptoms, signs, and pathology, are the same as are
met with in the adult. Several cases of latent pericarditis are recorded, but we cannot
say that this latency is more common in the child than the adult. It is, however, pro-
bable, that in its uncomplicated forms the disease is more often latent in the child and in-
fant. Dr. Lees has given an example occurring at the age of four months. The disease
was exceedingly obscure. The infant looked ill, and seemed to suffer severe internal pain.
Death occurred after long-continued convulsions, and the only morbid appearance found
was a thick layer of greenish lymph, spread over both surfaces of the pericardium. In this
case there was no cough, nor impeded respiration. (See the Transactions of the Patho-
logical Society of Dublin for January, 1841.) The work of Billard, “Maladies des
Enfans,” may be consulted ; also, the great work of Cruveilhier.

INFLAMMATION OF THE HEART.

lower sternal region, was soon afterwards admitted into hospital
with the following symptoms, which were of four days’ stand-
ing:— Fever of an inflammatory type; pulse small, weak, and ra-
pid ; hurried and difficult breathing, great tenderness of the surface,
and pain in the lower portion of the chest. With the exception
of dulness on the anterior portion of the right side, there was no
physical sign of thoracic disease observable. Next day the pain
was fixed in the lower portion of the right side ; the respira-
tions were 48 in the minute, and the pulse irregular. The breathing
soon became completely thoracic, yet no sign of pulmonary dis-
ease could be detected. On the day before his death he was seized
with a violent stitch in the left mammary region. The intermis-
sions and irregularity of the pulse increased, and for the first time
intense rubbing sounds were discovered over the heart, attended
with distinct friction sensations communicated to the hand. His
death took place on the eighth day of the attack.

On dissection, the heart was found greatly enlarged and ex-
tending to the right side, so as to displace the lung. The peri-
cardium presented evidences of chronic and of acute disease. A
cartilaginous band, of nearly an inch m width, connected the heart
a little above the apex with the outer fold of the pericardium, and
the whole of the internal surface of the sac had a mammilated ap-
pearance, produced by depositions of a semi-cartilaginous consist-
ence, super-imposed on which was a layer of soft lymph, of a deep
red colour. The valves were healthy, and no change beyond
cadaveric engorgement was found in the lungs.

The true nature of this case was not discovered until the
day before its fatal termination. It was the first in which I ven-
tured to make the diagnosis of pericarditis from physical signs,
and it furnished the basis of subsequent investigations11. This case
occurred in 1830. It has been already alluded to in the present
work, as bearing on the question of the effect of enlargement of
the heart in causing that extension of pericarditic sounds which
may lead to their being mistaken for the signs of diseased valves.
There is every probability that there were two attacks of pericar-

» Researches on the Diagnosis of Pericarditis, Dublin Journal of Medical Science,
First Series, vol. iv. (1834), Case I.

PERICARDITIS.

ditis, and that the fatal seizure lasted six or seven days. There
were evidences of a chronic pericarditis, on which an acute he-
morrhagic attack appears to have supervened.

This case has been already referred to in the present work, as
showing that even with an hypertrophied heart the sounds of fric-
tion may not extend beyond the limits of the organ.

We would gain little by dwelling on cases of uncomplicated
pericarditis, the characters of which are now so well known.
Let us rather study the disease in its combination with other
affections.

But before entering on this part of the subject, we must refer
to some observations by Dr. Mayne, which show that an inflam-
matory effusion may take place into the pericardium, and yet no
friction sound be developed. Cases of this kind are rare, and the
want of friction signs depends on the nature of the secretion and
the smoothness of the surface It will be remembered, that in the
instance recorded by Dr. M‘Dowel no friction sound was disco-
vered. The heart was bathed in purulent matter, so that from the
moment of the formation of the fistula we may suppose that a
fluid of great lubricity covered the organ. Further, it is probable
that in some of the sub-acute cases, with an effusion almost purely
serous, there would be no friction, unless, perhaps, when the sur-
faces came into contact on the absorption of the liquid.

Dr. Mayne has given two cases in which friction signs were
not developed. In one, effusion into the pericardium was found
on the first examination sufficiently extensive to cause dulness
of the region of the heart. The patient, a woman, was then
forty-eight hours ill, but it is probable that had she been seen
at the onset of the disease some friction phenomena would have
been discovered. The symptoms were, irregular action of the
heart, with an exceedingly weak and sometimes imperceptible
impulse. Both sounds could be distinguished, but without any
friction or bellows murmur. The pericardium was found greatly
distended with liquid of a sero-purulent character, and a similar
effusion existed in both pleune. Fragments of false membrane
existed upon the surface of the heart.

In the second case it is more than probable that friction signs
were never developed. It was one of acute anasarca, succeeded

INFLAMMATION OF THE HEART.

by diffuse inflammation of the cellular membrane of the neck,
chest, and abdomen. The parts affected were exquisitely tender,
the pulse very rapid and small, and the fever well marked and of
a typhoid type. The patient complained of slight uneasiness about
the heart, but nothing peculiar was discovered by the stethoscope.
The action of the organ was very rapid and weak, but there was
no frottement , or other unnatural sound. Death took place on
the second day of the diffuse inflammation ; and on examination
the pericardium was found to contain seven or eight ounces of
thin pus. There were no false membranes. The pericardium pre-
sented some vascular patches.

Dr. Mayne observes, that the stethoscopic signs of pericarditis
were never developed in this case, which he accounts for by the
fact that no lymph had been secreteda.

We may now proceed to examine some instances of pericar-
ditis occurring in combination with other affections, both local and
general.

Case III .—Acute Pericarditis with Pneumonia and Arthritis.

A man, aged 35, was admitted on the tenth day of his illness,
with symptoms of severe pneumonia complicated with arthritis.
He had been first attacked w7ith pain and oppression at the prse-
c.ordia, with severe dyspnoea and cough, followed in the course
of twenty-four hours by articular inflammation in the lowei ex-
tremities and left arm. On admission he appeared monbund ;
his countenance was sunken and anxious ; he had laborious res-
piration, with frequent cough, attended with muco-purulent expec-
toration, which the night before had been tinged with blood;
the knee-joints were inflamed and painful, and he had dull pain
at the lower portion of the sternum, increased by coughing and

a See Hr. Mayne’s Observations on Pericarditis, Dublin Journal of Medical Science,
vol. vii. Though we admit that in cases of sub-acute pericarditis with an almost purely
serous effusion, and again in others where a purulent fluid is produced from the first, fric-
tion signs may be absent, yet these are exceptional cases, and their occurrence furnishes
no argument against the utility of physical diagnosis in this disease. Vi hen wo recollect
that friction signs and dulness may coincide, and that unless in a case observed from its
verv commencement, we cannot absolutely say that friction signs never occurred, it will
appear plain that the number of instances in which these phenomena were absent will
be found to be exceedingly small.

PERICARDITIS.

by pressure at the epigastrium ; pulse 96, feeble, small, but re-
gular; the chest sounded well anteriorly. There was some dulness
over the inferior portion of the right side, and here, as well as in
the corresponding part of the left side, an intense crepitating rule
was manifest.

The sounds of the heart were peculiar, and varied remarkably
with the position of the stethoscope ; when applied over the left
side of the heart, the pulsations were found to be accompanied by
a sound resembling an indistinct bnrit de rape ; but along the
lower part of the sternum there was an exceedingly loud and per-
fect friction sound, which accompanied both the systole and dias-
tole of the heart. Towards evening the patient, after having taken
some stimulants, was found in a state of general re-action. On the
following day the pulse was 88 in the minute, perfectly regular,
and somewhat contracted ; he said he had no pain in the lower
part of the sternum, except when he coughed ; the impulse of the
heart was natural, and the lower part of the sternum continued
clear on percussion.

The frottement and simulated bruit de rape continued as yes-
terday, but a new and remarkable phenomenon was observable :
every four or five beats a change of character occurred with great
regularity, constituting a most perfect rhythm. This was found
to be connected with the respiratory movements, the sound being
roughest and most intense during inspiration, but during expira-
tion becoming feebler, and more like the bellows murmur. On the
following day, the 12th, we found that the phenomena of the
heart were distinctly modified, as compared with the day before ;
the rasping sound being now distinct at the left side of the heart,
and wanting at the right, where a double bellows murmur was
audible; the distinctness of which was, as before, modified by the
action of respiration.

Three days having passed, we could still feel a slight fremitus
over the heart, the rasping character of the friction sound had dis-
appeared, and the region of the heart sounded clear. The next day
the harsh rubbing sound had completely disappeared, the sound
being a pure double bellows murmur. At this time the patient’s
general state was greatly improved; in a few days, however, the
pulmonary symptoms re-appeared, with an increase of the pheno.-
VOL. i. f

INFLAMMATION OF THE HEART.

mena of the pericarditis ; some time after this he sunk. We were
not able to obtain a dissection.

The treatment consisted of local bleeding, counter-irritation,
and the use of colcliicum and mercury.

In this case, although we cannot appeal to the results of dis-
section, yet I would submit, that there can be but little question
as to the nature of the disease and the physical alterations of the
pericardium. This was obviously a case of dry pericarditis: the
patient, as happens in many instances, laboured under a compli-
cation of disease ; the right lung being severely affected, and the
articulations the seat of an obstinate inflammation. We may here-
after inquire how far this circumstance of complication may serve
to explain the occurrence of that variety of pericarditis in which
lymph alone is effused. It is at all events remarkable that in
most of the cases of this disease that I have witnessed, the pa-
tients laboured wider inflammation in various organs and in dif-
ferent tissues.

This patient presented stethoscopic phenomena perfectly ana-
logous to those observed in the former cases, where we had an
opportunity of verifying our diagnosis by dissection. The sound
on percussion over the heart continued clear, and the impulse of
the organ was always distinctly perceptible, and accompanied
by a rubbing feel ; circumstances tending to show the non-exis-
tence of liquid in the cavity of the pericardium. During the
progress of the disease we observed those remarkable changes
in the character of the sounds which I have noted in the preced
ing cases: the passage of the rough rasping sound, to one giving
the idea of a smoother surface; the first similar to the bruit ce
rape, the second to the bellows murmur. But in this case two
other circumstances of importance are to be noted.

First, the change of situation of the rasping sound. It will be
recollected that at first this was most distinct at the right side of
the heart, but that shortly after it became evident at the left,
where previously a sound similar to a double bellows murmur was
only audible. This I look upon as a circumstance of great im-
portance in the diagnosis between this disease and affections of
the valves. It may happen, as I have often myself observed, that
in cases of extensive valvular disease the rasping sound may pass

PERICARDITIS.

into a bellows murmur, in consequence of the moderated action ol
the heart, the result of rest or treatment. On excitement taking
place, however, the original sound will be restored. But here we
have a change, first in character, and secondly in the actual situ-
ation of the sound, a circumstance easily explicable by the exten-
sion of the disease and the modifications produced in different
portions of the pericardium. The slight extent to which these
sounds are audible, unless during great excitement, gives addi-
tional weight to this explanation. I do not know of any case of
valvular disease in which the rasping sound was observed, in the
course of twenty-four hours, to change from the right to the left
side of the heart.

Secondly, the modification produced in the sounds of friction
by the action of respiration. It will be recollected that the rub-
bing sounds became more distinct, and conveyed the idea of a
rougher surface during inspiration; during expiration they be-
came less distinct, and closely approached to the bellows murmur.
We found further, that if the patient held his breath, the charac-
ter of the sound was between these two extremes, and that the
peculiar rhythm ceased, evidently showing that it was produced
by the action of respiration.

Case IV. — A cute Arthritis; Pericarditis; double Pleura-pneumo-
nia ; recovery.

Frances Kelly, aged 24, of a vigorous constitution, was at-
tacked on the 25th of March, 1833, with symptoms of severe
arthritis, affecting most of the articulations. She had consi-
derable inflammatory fever, but no pain whatever in the chest.
Previous to this illness she had enjoyed the best health. In
the course of six days she was admitted into the Meath Hos-
pital, where I found her labouring under a general arthritis,
although none of the joints were in a state of excessive inflam-
mation. She had high fever, and a full, strong, and perfectly
regular pulse, no pain of the chest, cough, or dyspnoea. The
heart’s action was strong, and a slight friction sound, teas audible
near to the apex.

Free bleedings, both general and local, were ordered. The

f 2

INFLAMMATION OF THE HEART.

tartar emetic treatment was pursued for nearly five days, when we
had to desist from the occurrence of vomiting and purging.

On the seventh day after her admission I found her in a state
of high fever, and complaining of severe pains in the joints,
which, however, did not show any corresponding increase of in-
flammation. The pulse full and hard, 130 in the minute; respi-
ration 40. The increase of fever, without increase of arthritis,
led me to suspect some severe visceral inflammation, and I di-
rected my attention to the heart, but could not discover any un-
equivocal sign of disease.

Next day, however, there was decided evidence of the ex-
istence of inflammation both in the pericardium and left lung.
The left side of the chest in its lateral and inferior portions
sounded dull, and the respiratory murmur had become feeble ge-
nerally. In addition to this, a decided pleuritic frottement could
be heard in the antero-inferior portion. That it proceeded from
pleuritis was obvious from this, that it was synchronous with
respiration, and whenever the patient held her breath the sound
altogether ceased.

The sounds of the heart were accompanied by a loud rasping,
occurring with both sounds. This was very loud at the base of
the heart, and scarcely audible at the apex. Under the clavicle,
and in the posterior portions of the chest, the sound was inaudi-
ble, although the pulsations of the heart were distinctly heard.
No fremitus was perceptible. Her countenance was extremely
anxious ; she declared that she had no pain in the chest, but had
a sensation of sinking about the heart, with distressing palpita-
tion; great prostration, but no syncope; she was apprehensive of
speedy death; respiration hurried, but not difficult; pulse 124,
hard and thrilling, but regular. She had slept badly, and begged
for a narcotic. Leeches, calomel, and digitalis.

On the next day, although there was an evident improve-
ment in the general symptoms, the rasping sound had extended
over the whole region of the heart. The following is the report
of the 10th : —

The anxiety and sense of sinking are much diminished;
breathing easier; pulse 110, soft and full; impulse of the heart
less; urine scanty and high-coloured ; no mercurial action. The

PERICARDITIS.

friction sound continues distinct over the whole region of the
heart, but has lost much of the roughness, and passes into bel-
lows murmur; the left side still sounds dull. No examination was
made of the posterior portions of the chest.

11th. The rasping sound was found to have ceased at the
apex, but it still continues at the base of the heart with evident
fremitus. Under both scapulae a distinct pulmonary friction
was audible, and the right side had become dull on percussion.
Blister, mercurial frictions.

12th. General improvement; the friction sensation of the
heart had nearly disappeared, being only perceptible at the
sternal end of the third rib. No change in the pulmonary
signs.

13th. All friction sensation had disappeared from the heart,
but from our unwillingness to disturb the patient, no examination
was made of the posterior portions of the chest. No ptyalism had
been produced.

14th. The patient was not so well. The disease in the lungs
showed but little disposition to resolve, and the rasping sound re-
appeared'at a point which could be exactly covered with the
stethoscope over the right side of the base of the heart. It was
heard nowhere else : there was neither rasping nor the simulated
bellows murmur on any other portion of the heart. I now deter-
mined to leech the right side freely, and to again try the tartar
emetic treatment, particularly as throughout the case the appetite
had continued good and the tongue generally clean. She used
the remedy for six days, at the rate of six grains each day, with
gradual improvement in the pulmonary symptoms. The region
of the heart, however, became extensively dull, the rasping sound
continuing at its base. The dulness gradually subsided, and on
the 22nd of April the sound over the heart was perfectly natural,
and the pulmonary congestion nearly removed. The following is
the report of the 24th : —

The phenomena of the heart are now perfectly natural.
There is still some dulness over the posterior and lateral portions
of the right side, with some friction sound.

In a few days this patient was quite convalescent, .and the

INFLAMMATION OF THE HEART.

most minute examination of the heart could detect no departure
from the state of health.

Let us now consider this disease under certain pathological
and mechanical conditions.

Case V. — Pericarditis supervening on acute Empyema of the
right Side ; Protrusion of the Diaphragm , and Displacement of
the Liver.

Patrick Murphy, aged 40, was admitted into the Meath Hos-
pital on the 22nd of March, 1833. On the 15th (seven days be-
fore admission), he was attacked by a rigor, followed by acute pain
in the right side. On admission, he complained of a severe stitch
in the right side, aggravated by coughing and inspiration ; his ex-
pectoration was scanty, and consisted of mucus and serum ; respi-
rations 54 in a minute ; pulse 106, small and hard ; tongue very
foul, with redness at the edges and tip; thirst, and epigastric ten-
derness.

On percussion we found that the right side, both anteriorly
and posteriorly, sounded dull, particularly in its more inferior por-
tions, where the integuments were exquisitely tender. This side
was also found an inch larger, by measurement, than the other,
and no vibration was communicated to the hand when the patient
spoke, though this was distinctly felt in other parts of the chest.
Respiration over the superior portions of the chest was heard feebly ,
and we observed a doubtful aegophony under the scapula. The
liver was observed to extend about an inch below the ribs, forminga
tumour exquisitely tender on pressure; decubitus on the affected side.

Active treatment was adopted, the patient was bled generally
and locally, and calomel and opium were exhibited in free doses,
but no effect appeared to be produced on the disease, as on the
24th the dulness was found to have extended, the side still more di-
lated, and the intercostal spaces elevated. On the 29th we found
that both sides corresponded in measurement, yet there was no
appreciable improvement in the other symptoms; no satisfactory
mercurial action had been induced, although the patient had been
dailv using mercury. On the following day it was observed that
the dulness extended quite across the sternum, and the respira-

PERICARDITIS.

tion in the superior portion of the lung had assumed a bronchial
character. We also observed, for the first time, a well-defined
sulcus existing between the false ribs and tho supenoi poition ol
the hepatic tumour. On the 31st it was found that the patient
had suffered greatly from orthopnoea during the night, and at the
hour of visit he could scarcely breathe in the recumbent posture.
The hepatic sulcus was more defined, and the liver evidently
pushed towards the left side; respirations 40; pulse 92, small,
feeble, but perfectly regular.

On examination, I found that the region of the heart sounded
clear on percussion ; its impulse could be distinctly felt ; and evi-
dent fremitus was communicated to the hand when placed over
the cardiac region. The action of the heart, though rapid, was
perfectly regular, and a morbid sound between that of the craque-
inent cle cuir neuf and bruit de rape was distinctly audible.
The patient declared he had no pain whatever in the region of
the heart, but stated that during the last two days he had felt
some slight uneasiness in that situation. On the next day he
was obviously sinking, there was some delirium, and the pulse
for the first time became intermittent. We observed that the
hepatic sulcus, which for the last two days had been so well
marked, was now nearly imperceptible ; the sound of friction
continued the same as on the day before. The patient died
shortly after the hour of visit.

Dissection. — On opening the abdomen, the thin edge of the
rio-ht lobe of the liver was found to descend as low as the uinbili-

cus, the left lobe extended into the corresponding hypochondrium,
and the horizontal fissure was nearly in the direction of the me-
dian line, though inclined slightly across it. The hepatic tissue
was soft, and of a red colour, and we observed that the sulcus be-
tween the under surface of the diaphragm and the upper portion
of the liver was very inconsiderable.

On removing the liver, its diaphragmatic surface was found to
present a singular appearance. It had yielded to tire pressure of
the convex diaphragm, so as to present a concavity of great size,
into which the right portion of the diaphragm accurately fitted.
When the viscera were removed from the abdominal cavity, this
portion of the muscle, distended and rendered convex by the

7 2

INFLAMMATION OF THE HEART.

thoracic effusion, presented a most striking contrast with the left,
which was in its natural state. Some adhesions existed between
the upper portion of the liver and the diaphragm.

The right pleura contained upwards of nine pints of an opaque,
whey-coloured fluid, and was universally lined by a thick layer of
flocculent lymph. The lung compressed, and, presenting wrinkled
folds, lay against the mediastinum, its lower lobe somewhat pro-
jecting, and separated from the diaphragm by a large space. In
its antero-superior portion was a cavity of the size of a walnut,
filled with thick, brownish yellow pus ; this was covered exter-
nally by the pleura. On opening the pericardium we found its
surface universally covered with lymph of a reddish colour, and
formed into small, irregular masses or granules ; but there was no
adhesion. The whole surface was thus rendered exceedingly
rough, particularly towards the apex, the situation in which, din-
ing life, the friction sound had been loudest, and most resem-
bling the bruit de rape. The lower portion of the ileum was
in a state of great vascularity, and its mucous coat softened.

In the second case of this disease which I have recorded, we
had an example of latent dry pericarditis supervening upon an old
empyema of the left side, which had produced great displacement
of the heart. In the present instance, however, we see the same
disease following a recent pleuritic effusion of the right side, with
extensive displacement of the liver. In both cases the disease was
recognised, and the diagnosis verified by dissection, although none
of the usual symptoms of pericarditis were present, and although
the patients never complained of any uneasy sensations referred
to the heart. In both, too, the diagnosis was founded on this prin-
ciple, the appearance of the phenomena of fremitus or rustling , as
felt by the hand , with the stethoscopic signs as described , in a case in
which, a very short time before , no such phenomena existed.

In these two cases, although the pulse was regular, the action
of the heart not altered in any new manner, pain absent, and the
sound on percussion clear, yet a universal pericarditis was detected.
I need scarcely remark that in this case our diagnosis was much
strengthened by the observations on the former one. In one re-
spect our diagnosis of these cases differed: in the foimer, the
gradual cessation of the phenomena, except over the base of the

PERICARDITIS.

heart, while the region of this organ continued clear on percus-
sion, led us to conclude that a process of obliteration had taken
place extensively ; while in that before us, the persistence ol the
phenomena, both as to extent and intensity, enabled us to declare
that no obliteration of any part of the cavity of the pericardium
had taken place. The examination of the cases will show the
correctness of the diagnosis in both instances.

Three circumstances are worthy of notice in this important
case : —

1. The supervention of pericarditis in its last period.

2. Its occurrence in a heart under the influence of excentric
pressure.

3. The absence of all the usual symptoms of the disease, whe-
ther as regards pain or abnormal action of the heart.

In the case next to be given of the combination of empyema
and pericarditis, the left pleura wa3 the seat of the effusion.

Case VI. — Extensive Empyema of the left Pleura ; Dexiocardia;

acute latent Pericarditis; intense Friction Sound, disappearing

ivitk a nearly complete obliteration of the Pericardial Sac.

A man named Lennon, aged 28, was brought to the Hospital
early in January, 18 — , labouring under the most aggravated
dyspnoea. On examination I detected an extensive empyema of
the left side, and the heart was observed to pulsate to the right of
the sternum, but presented no morbid sound whatsoever. His
symptoms had been at least of four months’ standing, and he
stated that he had observed the displacement of the heart a month
previous to his admission.

On the 1st of February the patient came under my care, the
displacement of the heart continuing, but without the occurrence
of any morbid sound in its pulsations. He was treated by mild
mercurials and narcotics. In the course of the week he began
to suffer extremely from flatulent distention of the belly. On
the 10th I made a careful examination of the whole chest. No
change whatever was observed in the stethoscopic phenomena or
impulse of the heart, but on the 12th, having placed my hand ac-
cidentally over the displaced heart, I was astonished at feeling
a most distinct fremitus over its entire region, giving to the

INFLAMMATION OF THE HEART.

hand a sensation of two very rough surfaces rubbing violently
one upon the other. On applying the stethoscope we found that
the sound varied over different portions of the heart. At the base
it was similar to the friction sound in ordinary cases of dry
pleurisy, but towards the apex it closely resembled the bruit de
rape of Laennec, its point of greatest intensity being between the
upper border of the third and lower of the fourth rib. We ob-
served also that, if the stethoscope was moved to a distance of not
more than an inch and a half from the situation of the heart,
these remarkable phenomena ceased, though the contractions of
the organ were heard distinctly. Pulse about 130, small, but not
at all irregular ; the sound of friction accompanied both sounds of
the heart ; dyspnoea very urgent, but the patient made no com-
plaint whatever as connected with the heart. The cardiac region
was freely leeched, and the patient ordered digitalis.

loth. The fremitus is remarkably diminished; the sound is
analogous to the double bruit de rape ; heart’s impulse less; no
increase of dulness on percussion. From this period till the 17th
the sensation and sound of rubbing gradually disappeared ; it was
only by close questioning that the patient admitted he had some
pain at the right of the sternum.

On the 18th all fremitus and rasping sound had disappeared,
except in a spot which could be covered by the stethoscope over
the base of the heart and to the right side. In this situation a
sound between frottement and a bruit de rape was distinctly audi-
ble. The patient sunk on the 22nd.

Dissection. — The left pleura presented the usual appearances
which occur in extensive and chronic empyema, its cavity con-
tained nearly a gallon of sero-purulent fluid. The right pleura
contained about a pint of perfectly clear serous fluid, and pre-
sented no effusion whatever of lymph on its surface. The peri-
cardium appeared increased in size; it had lost its semi-trans-
parency, and could not be made to glide over the heart. On
opening its cavity, we found, with the exception of a small space
at the base of the heart, exactly corresponding to the situation
where the friction sound was last heard, that it was completely
obliterated by recently effused lymph, which was reddish, and
though soft, presented a considerable degree of consistence ; so

PERICARDITIS.

that when the two folds were separated by traction a vast number
of laminae, perpendicular to the surface of the heart, made their
appearance. On the anterior portion of the ventricles, towards
the apex, the union of the two surfaces was complete. Here the
quantity of effused lymph was evidently much less than in the
other parts of the cavity. Around the origins of the great vessels,
particularly towards the right side, no union had taken place be-
tween the surfaces of the pericardium. Each face, however, was
covered by lymph, presenting a considerable consistence, and
giving the appearance which is produced when two smooth sur-
faces covered with a tenacious matter are suddenly separated.

This case I look on as one of extreme importance, as it was
the first in which the positive diagnosis of an effusion of lymph on
the surface of the pericardium was verified by dissection ; and it
must be recollected that the heart was extensively displaced by
an empyema, and that the patient scarcely, if at all, referred any
uneasy sensation to the situation of the recently suffering organ.
The diagnosis was founded on the following circumstance, viz.,
the sudden appearance of the fremitus, and of the sound similar
to the bruit de rape, in a case which had been long under ac-
curate observation, and which, two days previously, presented no
such signs.

But in the progress of the case we added to our diagnosis, and
I recorded it as my opinion that adhesion had taken place every-
where except over the base of the heart. This diagnosis was ar-
rived at from observing the rapid subsidence of the signs under the
influence of treatment, except in the above situation, the region of
the heart still continuing clear on percussion ; a proof that the disap-
pearance of the signs was not owing to a liquid effusion ; which
opinion was still further rendered probable by the impulse of the
heart continuing to be felt with the utmost distinctness.

The latency of pericarditis in both these instances would be by
some attributed to the fact of its invasion during the last periods
of life, but I do not believe that this explanation can be received,
for I have witnessed the invasion and cure of pericarditis during
the progress of an extremely chronic empyema of the left side oc-
curring long before the death of the patient. Of this the follow-
ing case is a good illustration: —

INFLAMMATION OF THE HEART.

Case VII. — Chronic Empyema of the left Pleura; intercurrent
latent Pericai'ditis affecting the displaced Heart.

A woman, aged 26, after exposure to cold was attacked on
tlie 10th of December, 18—, with symptoms of acute pleurisy
of the left side. These had continued for nine days, when she
was admitted into the Meath Hospital, with the usual symp-
toms and signs of extensive effusion into the pleura. The heart
pulsated to the right of the sternum and in the epigastrium, hut
its sounds were natural. On the fourteenth day of her residence
in the Hospital my friend, Dr. Thomas Brady, under whose spe-
cial care the patient had been placed, discovered for the first time
pericardial friction sounds in the displaced heart. It was stated
to him by some of the pupils that these phenomena had existed
for a few days previously. No new symptom attended this ex-
tension of disease; the pulse had not changed in character; it
was 96, small and feeble; nor is there any notice of its ever hav-
ing been irregular while the pericarditis continued. On the day
when the sign was first observed the heart could be seen pulsat-
ing in the epigastrium; its sounds were audible over the anteiior
portion of the chest, but they had a peculiar muffled character,
as if some soft body intervened and deadened them. Over the
right side of the chest, and along the cartilages of the third,
fourth, fifth, and sixth ribs, distinct double friction sound was
' audible, loudest at the line of the mamma, and persisting when
respiration was suspended. These two sounds were followed by
another, which was short and sharp; and the whole might be thus
expressed: pu-pu-pi. No one symptom indicative of pericarditis

existed.

Nine days elapsed, and the friction signs on the right side and
across the sternum were even more distinct. Their intensity dimi-
nished, however, as the left side was approached, until they disap-
peared, leaving the sounds of the heart without friction, but still
with the muffled character before noticed. Posteriorly the sounds
of the heart were unaccompanied by any attrition sign, and per-
cussion gave no evidence of pericardial effusion. No change was
observed for seven days more, when it was found that the
friction was scarcely perceptible; it could be detected at the car-

PERICARDITIS.

tilage of the fourth rib, and the sounds of the heart had lost the
muffled character. From this period there was no return of pe-
ricarditic signs, although the patient lived for four months after-
wards.

We have now reviewed three cases of the combination of
empyema and pericarditis, and in them all we see a dry pericar-
ditis, only revealed by physical signs. So latent, indeed, was the
disease, that its existence would have never been suspected had not
the employment of the stethoscope, in examining the progress of
the pleuritic disease, led, as it were, accidentally to its detection.
And yet, as has been before remarked, the heart was in all these
cases under pressure. In two it was dislocated to the right side,
and in one it must have suffered great pressure when we consider
that the effusion actually displaced the liver.

The latency of the disease in these cases is to be explained by
referring to the general law that the pre-existence of an impor-
tant local or general disease seems to act in preventing the
development of symptoms in the new affections that may be super-
added. We cannot refer in these cases to the fact that the dis-
ease only supervened in the last periods of life ; for, as we have
seen in the last-mentioned example, the patient lived several
months after the subsidence of the pericarditis.

Finally, the singular duration of the friction phenomena in the
first case described demands our special notice. It is certain that
they continued for sixteen days, and there is reason to believe that
two or three days may be added to this period. I have never met
with a case in which so long a time passed before organization of
the false membrane took place, and the circumstance can only be
explained by referring to the condition of the patient, who was
all through suffering from aggravated symptoms of empyema,
with copious expectoration and severe constitutional disturbance.

Case YIII. — Acute gangrenous Abscess of the Lung ; Pericarditis.

Of this combination I have observed a single instance. A man,
aged 40, died after a fortnight’s illness. His symptoms had been those
of an acute pneumonic inflammation, and on admission his breath
and expectoration revealed the existence of putrefactive action in
the lung. The right side was generally dull on percussion, except

INFLAMMATION OF TIIE HEART.

at the root of the lung, where a cavity was detected by the usual
signs. The pulse was feeble, and it is to be regretted that no
careful examination was made of the heart. He died on the day
of his admission. On dissection, the right lung was found in a
state of purulent infiltration, and containing many small ab-
scesses, some of which were quite superficial, and only covered by
the pleura. The upper lobe was in the state of red hepatization.
A cavity existed in the postero-inferior portion, the walls of
which were gangrenous, and it contained a quantity of foetid
matter ; many of the smaller abscesses were surrounded by a dark
margin. The pericardium was everywhere covered with a coat
of finely granular lymph. On applying the hand to the heart,
the same sensation was produced as that from rubbing the
tongue of a cow. The kidneys were in an advanced stage of

Bright’s disease.

Though we want a sufficiently extensive observation to
warrant the conclusion that pericarditis, when combined with
chronic disease of the lung, is generally latent, there appear
strong grounds for such an opinion. Hence we might expect
this latency in the combination of pericarditis with chronic tu-
bercular disease, and the experience of Dr. Law goes strongly to
confirm this viewa; it is further probable that in a large pro-
portion of the cases of complication with essential diseases, more
or less of the character of latency will be observed. Hence, in
cases of typhus fever, in the eruptive diseases, in dififuse inflam-
mations, in erysipelas, and phlebitic and puerperal fevers, we may
expect to meet with the character of latency, so far as symptoms
are concerned, as much or even more than in rheumatic fever.

a In a case of phthisis recorded by Louis, Recherches Anat. Path, sur la Phthisie,
Obs. 19, pericarditis supervened during the last month of the patient s life. The
pulse was frequent, unequal, irregular, and sometimes intermittent, and the impulse of
the heart was increased. The invasion of the pericarditis, however, occurred siniu ta-
neously with that of a pleurisy of the right side; but there was no important symptom
of the heart affection beyond the characters of the pulse. See also, Andral, Maladies i e
Poitrine, Obs. 5. r

See the Transactions of the Pathological Society of Dublin, January, 1841- r‘ a"

exhibited a series of specimens of pericarditis, and in all those cases combination w ith chi
or acute disease of the lung existed. The pericarditis was principally detected by its tac-
tile and acoustic signs.

PERICARDITIS.

Wc find the following illustrative case in the Clinique Medicale
of Andral: A lad, aged 17, was attacked with stnall-pox, which
ran its usual course up to the seventh day, when, just as the pus-
tules wmrejin full maturation, the patient was attacked suddenly
with dyspnoea. There was no cough nor bloody expectoration.
During the eighth and ninth day the eruption remained sta-
tionary; then some of the pustules became black; others were
filled with a reddish serosity, and between them livid petechias
made their appearance. The dyspnoea increased, and death took
place on the tenth day. A sero-purulent effusion into the peri-
cardium, and a vivid injection of the great cul de sac of the sto-
mach, were the only morbid appearances discovered.

COMBINATION OF PERICARDITIS WITH ANEURISM OF THE AORTA.

This combination appears to be rare, a circumstance the less
remarkable when we bear in mind the infrequency of acute in-
flammation in aneurismal cases. Hence, the frequency of death
by rupture into a serous sac. No case of the combination in ques-
tion has occurred to myself, but the following example possesses
some points of interest. It was communicated to the Pathological
Society by Sir Philip Crampton, in 1845 :

A soldier, who had served in tropical climates, after having
laboured under symptoms supposed to be those of pleuritis, was
attacked suddenly with severe pain in the thorax. On examina-
tion Dr. Tice, the attending surgeon, discovered a pulsating tu-
mour under the right mamma. After a few days he was seen
by Sir Philip Crampton, who found a large pulsating tumour
displacing the right pectoral muscle upwards and forwards. Its
impulse was very strong, while that of the heart itself was feeble,
and only one sound, believed to be the first, was audible. The
diagnosis of aortic aneurism was made, and it was conjec-
tured that a liquid effusion existed in the left pleura. On dissec-
tion a large false aneurism, with an opening into the vessel capa-
ble of admitting the thumb, was discovered. It sprung from the
commencement of the second portion of the arch, and adhered
anteriorly to the thoracic walls. From one of the ribs the perios-
teum had been removed by the action of the aneurism. The

INFLAMMATION OF THE HEART.

heart was not hypertrophied, hut the pericardium was extensively

inflamed, and the sac filled with fluid.

We here observe another instance of pericarditis arising in
connexion with a chronic disease within the thorax, and with
obscure or doubtful symptoms. The most interesting point, how-
ever, in the case, is the fact that in its advanced periods the heart
gave but a single sound. Nobody can more fully admit the danger,

I might almost say the impropriety, of discussing a recorded case
while we assume that there has been an error in the observation ;
yet I cannot help believing that the single sound heard in this
case was the second sound, and not the first, as stated in the
communication to the Pathological Society, an opinion which the
following circumstances seem to justify:

1st. That I have never observed the extinction of the second

sound of the heart in cases of aortic aneurism.

2ndly. I have noticed the weakening and almost complete
extinction of the first sound in pericarditis ; hence it becomes
more than probable that the single sound heard in this case was
the second sound, the extinction of the first being caused by
weakness and semi -paralysis of the ventricles, producing in this
way the physical signs which we observe in typhoid softening, 01

debility of the heart.

COMBINATION OF PERICARDITIS WITH TYPHUS FEVER.

When we recollect the rarity of secondary disease of the white
tissues in typhus, we may anticipate that the occurrence of peri-
carditis under such circumstances is seldom met with ; and,
so far as inflammatory affections are concerned, the heart
enjoys a singular exemption, as compared with other organs,
while the system is under the poison of typhus. Thus, out of
eighty-six cases recorded by Andral of death in severe fever, but
thirteen exhibited any trace of alteration of the heart; and it is
more than doubtful that the changes in these cases were of an in-
flammatory nature. I have myself only once observed the com-
bination in question, but my recollection of the case is not suffi-
ciently accurate to justify my giving it in detail. But while we
admit the rarity of pericarditis in the typhus fever of this coun-
try, we know that in many affections having the typhoid cha-

PERICARDITIS.

racter a latent pericarditis may be met with. Thus, it may
occur in the diffuse inflammations, in the acute pyogenic states,
in phlebitic disease, puerperal fever, the low forms of variola, and
other cases presenting the typhoid condition. After what has
been said it is unnecessary to dwell longer on this subject

TRAUMATIC PERICARDITIS.

There is no reason for believing that when the disease results
from a direct injury, such as a blow or wound, the accident is
attended by any special modification of physical signs. I have,
however, seen a case in which the friction phenomena were de-
veloped in an unusual manner. A man received the contents of
a gun, discharged at some distance from him, on the anterior
portion of the left side. The gun had been loaded with small
shot, and the pellets were scattered over a considerable surface,
many of them not penetrating deeper than the skin. Most of
these little wounds were received in the cardiac region, the inte-
guments of which were dotted with small black spots, under many
of which a grain of shot could be felt. The patient suffered
principally from faintness and nervous depression ; but that these
symptoms were not the result of carditis was evident from the
fact that they existed from the moment of his receiving the in-
jury. For two or three days there was no indication of pericar-
ditis ; but after this time, and when the collapse and nervous
depression had passed off, physical signs of a peculiar nature were
developed over the region of the heart. There was no dulness on
percussion, and the best idea of the signs may be given by stating
that they consisted in the existence of many distinct points of
intense friction sound, each of which, though extremely circum-
scribed, conveyed the impression of a resisting or cartilaginous
deposit. These signs continued for several days, during which
the friction phenomena subsided at certain points and appeared
at others. There was no constitutional suffering, and but little,
if any, local distress. The patient speedily recovered.

I think little doubt can be entertained that the pericardium
was injured, while the inflammation, instead of spreading over
the entire surface, was confined to the points of lesion. The

INFLAMMATION OF THE HEART.

character of the signs was such as I have never observed in idiopa-
thic disease.

TREATMENT OF PERICARDITIS.

Although the principles of treatment ot this disease are gene-
rally similar to those of pleurisy ; yet it commonly happens that
a more energetic practice is adopted in pericarditis than in inflam-
mation of the pleura. From the importance of the organ engaged
arises the apprehension of greater danger, and thus it often occurs
that while the most active means are employed, the risk atten-
dant on a too great weakening of the system at large, and also
of the muscles of the heart, is overlooked. Such a line of treat-
ment, especially as regards too free or repeated blood-lettings, is

unnecessary, and generally dangerous.

In examining this subject we must separate the more violent
cases of the primary disease, and perhaps also those instances
where, in the course of a rheumatic fever, there is an explosion of
pericarditis, from that larger class where the affection exists as
one of a group of irritations, or as a mild though intercurrent
disease. In such cases the boldness of treatment often betrays
the timidity of the practitioner ; he is terrified at discovering the
disease, and his mind is more occupied with its name than its na-
ture or actual condition. In this way great mischief is done, for
the debility thus produced disposes the disease to change from the
dry and comparatively innocuous form, to an unhealthy inflamma-

mation, attended with liquid effusion.

It is important, further, to observe, that although as above
stated, the principles of treatment of the more violent forms are
similar to those which guide us in acute sthenic pleurisy, yet the
analogy only holds good up to a certain point, for it will be found
that the period at which such treatment ceases to be advantageous
or safe arrives much sooner in pericarditis than in pleurisy. In
both diseases, it is true, we have to contend with a severe inflam-
mation of a serous membrane, but in pericarditis a more impoi-
tant and complicated apparatus is engaged, giving rise to dangers
foreign to the case ol pleurisy. The period soon anives when
either from inflammation, paralysis, or the combination of both,

PERICARDITIS.

the heart itself is weakened, and the patient is in danger of death
from syncope, so that persistence in the reducing treatment may be
followed by fatal results. The conclusion is obvious, that whatever
may have been the necessity for depletion at the outset of the disease,
we cannot press it in pericarditis to the same degree as in pleurisy.

In regulating our practice we derive great advantage from
physical examination. So long as the impulse of the heart conti-
nues vigorous, its sounds remaining without signs of progressive
diminution, and the patient’s strength unimpaired, the dangers in
question may be considered as remote ; yet here it is not to be
forgotten that the weakness of the heart, like that of the diaphragm
and intercostals in pleurisy, may supei'vene in a sudden manner.
In pleurisy such an accident is of comparatively slight importance,
but in pericarditis it is one of great danger, threatening paralysis
of an organ which is the fountain of life.

It is my conviction that the fatal result of some cases of peri-
carditis is mainly attributable to the perseverance, beyond the
proper time, in the antiphlogistic treatment ; the practitioner look-
ing at the disease merely as a case of serous inflammation, and
forgetting not only the results of irritation on muscular fibre, but
the effect of great losses of blood in producing re-actionn.

1 Dr. Hope strongly advocates the importance of energetic antiphlogistic treatment

employed with the utmost promptitude :

“ The loss of a few hours at first may be irretrievable, and hence hesitation and indeci-
sion may seal the fate of the patient. If the attack is recent, and the patient’s strength will
admit, blood should, in the first place, be drawn freely, and by a large incision, from the
arm of the patient in the erect position, so as to bring him to the verge of syncope. From
five-and-twenty to forty leeches, according to the strength, should then be applied to the
prsecordial region so soon as the faintness from the venesection disappears and re-action
commences, which generally happens in the course of from ten minutes to an hour or
two. Unless the pain be completely subdued by these measures, the leeching, and in
some cases the general bleeding also, may be repeated two, three, or more times, accord-
; ing to the strength, at intervals of from eight to twelve hours, or, what is a better rule
as soon as the pulse and action of the heart denote a recommencement of re-action.

“ It is not, however, in every case that so active a treatment is required. I have seen
a single prompt and abundant application of leeches, or a cupping, at once subdue every
! formidable symptom. When the patient, either from age, a feeble constitution, or the
1 Advanced state of the malady, cannot bear extensive depletion, local bleeding is, accord-
i ing to my observation, decidedly preferable to general ; but it should be practised effec-
i tually, by cupping to twenty ounces or more, or by the application of from twenty-five
i to thirty or forty leeches. When, from depletion having already been carried to a great

G 2

INFLAMMATION OF THE HEART.

Let us now suppose that we have a case of uncomplicated pe-
ricarditis in its earlier stages, and occurring in a patient whose
strength is but little impaired : in such a case a single bleeding
from the arm appears, on the whole, justifiable, but its repetition
Avill be a matter for careful consideration. Under these circum-
stances we must examine the force of the heart, not only as indi-
cated by the pulse at the wrist, but by the actual strength of the
impulse, and the character of the first sound especially. If the
impulse continues vigorous, and the first sound undiminished, we
may be less apprehensive of the use of the lancet. On the other
hand, if, after depletion, the impulse has manifestly declined in
force, while the first sound is lessened, great caution must be used
before we repeat the general bleeding.

extent, or from the advanced stage of the disease, it is not safe to draw much more
blood, yet it appears expedient, from the persistence of pain, &c., to draw some, I have
generally found that a smaller quantity drawn by cupping produced more effect than a
larger by leeching. The cause of this probably is, that by cupping it is drawn more ex-
peditiously. . , „ .

“ I may finally remark that, though blood ought to be drawn with all the vigour

that I have described when the usual indications for its emission exist, yet, in cases
where mercury is employed, as presently to be described, those indications so soon cease,
from the controlling power of this remedy, that the total quantity of blood lost will rarely
be considerable."

He adds:— “ I feel satisfied that a degree of activity, in the first instance, which to
some may appear excessive, is an ultimate source of economy to the strength of the pa-
tient for the disease is subdued at once, and the protracted continuance of depletoiy
measures, the most exhausting to the constitution, is rendered unnecessary.”- Op. Cit.

But, without denying that in some cases such a course as is here indicated may e
proper we must not forget the effect which this advice may have on some of our bre-
thren ’whose minds are not sufficiently purged of the erroneous doctrines of inflam-
mation, so long the opprobria of our Schools of Medicine and Surgery. There are many
who could not, like Dr. Hope, discriminate between cases requiring such a vigorous
treatment and those of a veiy different kind, -who know the disease only by name, and
are unaware that the former are the exceptional cases. On tins subject Dr. Wood has
some excellent remarks. After observing that the heart is often stimulated by great
losses of blood, he says:— “These are not arguments against blood-letting, but only
against its abuse. The application of the remedy is to be guided here exactly on the same
principles as in other cases of serous inflammations. The stimulating quality of the blood
should be reduced by depletion, and the direct sedative effects of its loss upon the heart
be obtained without pushing it to the point calculated to produce re-action. The theory
which urges to any risk in order to avoid the terrors of adhesion should not be allowed to
have any weight.” See his Treatise on the Practice of Medicine, Philadelphia, 1849 ;
Art. Pericarditis ; also Dr. Todd’s work on Gout and Rheumatism, 1843, p. 197.

PERICARDITIS.

The force of the contractions of the heart, as indicative of the
safety of farther bleeding, is only valuable when no intervals of
weakened action have occurred. Where it has been an unchanging
condition, and especially when the heart’s action is regular, or nearly
so, we may, of course in addition to other circumstances relating to
time, and the age and strength of the patient, adopt it as an indi-
cation that another bleeding may be performed without risk. But
our great reliance is to be placed on local bleeding, and the best
mode appears to be the employment of leeches, in relays, begin-
ning with twenty or thirty, and gradually reducing the num-
ber on each application. Two or three applications may be
made in the twenty-four hours, a warm poidtice being em-
ployed during the intervals. At the same time it will be advi-
sable to induce a mercurial action by such means as are within
our reach, and it is probable that the plan of giving a full dose
of calomel, — say from ten to twenty grains, — at long intervals,
as recommended by Dr. Graves, will best answer our expec-
tations. “ If,” says Dr. Graves, “ a person is seized with very
acute pericarditis, how unavailing will be our best-directed efforts
unless they be succeeded by a speedy mercurialization of the
system ! In proof of this assertion I might adduce a considerable
number of cases of pericarditis treated both in hospital and private
practice, and might triumphantly compare the results with those
obtained in the continental hospitals, as recorded by some of the
most eminent German and French physicians. When even the
most violent attacks of pericarditis are met with copious venesec-
tions, repeated leeching, and the rapid injection of calomel, few
patients will be lost. If, on the contrary, the practitioner relies
solely on the lancet ; if, in the beginning, as I have seen done, he
applies a blister over the heart, and if he defers the exhibition of
calomel, or insufficiently uses it, then will he have occasion to re-
gret the consequences, and witness either the speedy death of his
patient, or his condemnation to the sufferings entailed on him by
adhesions, valvular disease, and the other sequelaj of badly treated
pericarditis”11.

This method of using calomel is that advocated by Dr. John-

* Clinical Medicine, page 803.

INFLAMMATION OF THE HEART.

son in the treatment of the diseases of tropical climates, and con-
sists in the exhibition of scruple doses once or twice daily. The
patient must take no cold fluids, acids, or fruits, but should
drink freely of warm barley-water. By this treatment it is found
that mercurialization may be effected without producing any
considerable amount of abdominal distress ; and it is remaikable
that the action of the medicine is attended with an abatement
of fever, and a decided diminution in the frequency of the pulse.
Dr. Graves further states, that by using the remedy in this way
he has cured sixteen patients, without any permanent injury to
the constitution. Finally, he observes, that when, in cases ne-
glected at their commencement, the diminution of fever and re-
tardation of pulse does not follow the mercurialization of the
system, it is a bad sign; still worse is it if the fever increases, for
he believes, and in this opinion I agree with him, that this is
owing to an aggravation of the disease, and not, as is often sup-
posed, to the action of the remedy.

In the second stage of the disease our principal reliance must
be on blisters ; but we may apply leeches again and again on any
new excitement of the heart. At a more advanced period, when
immediate danger is not to be apprehended, and that liquid effu-
sion exists, we shall probably obtain advantage from the lepeated
application of tincture of iodine over the pericardial region ; but
this suggestion is made more from our favourable opinion of this
remedy in pleurisy, than from any actual knowledge of its effect
in pericarditis.

As to the use of digitalis in this disease, so long as fever ex-
ists, and the heart remains in the state of inflammatory ex-
citement, the remedy seems inefficacious. Again, in the more
advanced stages, and when the organ has been weakened, its
exhibition might be dangerous. There is a period, however, in
which we may employ the medicine, namely, when, after all feier
and physical signs of pericarditis have subsided, the heait acts
with undue force, a condition sometimes attended with valvular
murmur, but in other cases without it. In this latter instance
especially, we find advantage from small and repeated doses of
digitalis. Should the medicine disagree, the hydrocyanic acid
may be substituted.

PERICARDITIS.

On the use of stimulants in pericarditis little or no informa-
tion has been given by authors, yet they are often imperatively
called for. I am convinced that cases are often lost from want of
stimulation at the proper time. These considerations have pressed
strongly on my mind since I made my observations on the state
of the heart in typhus fever ; and it is certain that in every case
of dangerous pericarditis, after the first violence of the disease has
been subdued, we should be anxiously on the watch for the mo-
ment when the weakened heart requires to be supported and invi-
gorated.

The following circumstances should lead us to diagnosticate
a weakened condition of the organ in pericarditis: —

1. The feebleness, intermission, and irregularity of the pulse,
especially when these characters have not existed from the com-
mencement of the attack, and again when the feebleness of the
pulse coincides with a diminution or loss of the impulse.

2. The appearance of turgescence of the jugular veins, with
or without pulsation.

3. The progressive change in the character of the sounds of
the heart, more especially if it is the first sound that becomes
feeble or extinct. This is important, for, if the second sound re-
mains, we may conclude that the want of the first is owing to de-
bility of the ventricles, rather than to any intervening liquid effu-
sion.

4. The evidences of a weakened circulation, drawn from the
symptoms in general. Among these we enumerate pallor, cold-
ness of the surface, oedema of the extremities, and the tendency to
faint upon exertion, or even in a state of repose*.

It may be laid down as a general principle that there is no
local inflammation whatever, the mere existence of which should

a The modifications of the sounds and impulse of the heart, as bearing on the ques-
tion of the use of stimulants in other diseases, will be fully examined, when we in-
vestigate the subject of weakening of the heart, with or without organic change. The
importance of investigating the state of the heart in fever, as bearing on practice, has been
already shown. See Researches on the Use of Wine and the State of the Heart in Typhus
Fever, Dublin Journal of Medical Science, First Series, vol. xv. (1839). Also Dr. Hud-
son’s Memoir on the Connexion between Delirium and certain States of the Heart in
Fever, Op. Cit. vol. xx. (1842). The application of these principles to other forms of
disease is sufficiently obvious.

INFLAMMATION OF THE HEART.

prevent the use of wine, if circumstances require it. In two cases
especially, namely, cerebritis and pericarditis, we find the greatest
timidity in practice with respect to the use of wine. Yet, even
in the first case it may be required, and in the second its employ-
ment is imperative, when, as too often happens, excessive deple-
tion has been resorted to. Again, if the signs of muscular weak-
ness, such as we have indicated, have appeared; if there be evi-
dence that the heart, previous to the attack, was in a weakened
state; and lastly, when a collapsed or typhoid condition of the
system exists, we must give wine, quite irrespective of the physi-
cal condition of the heart. This may be done safely, and with
great advantage. In the following case wine was employed with
the best effects.

Case IX. — Two attacks of Rheumatic Carditis, within a period of
seven months, with an intervening seizure of apparently nervous
palpitation; use of wine ; recovery.

A young woman was admitted into my wards in December,
1850, labouring under acute arthritis. She was greatly prostrated,
and suffered much from the affection of the joints. Pressure over
the heart caused some uneasiness; but this symptom, and a slight
prolongation of the first sound, were the only indications of disease.
In a few days friction sound was audible over the base of the
heart. The prostration had increased. The treatment which
had been adopted was the use of mild mercurials with opium, and
the application of small numbers of leeches to the joints. On the
day on which we discovered the pericarditis wine was ordered, at
first with caution, but subsequently with greater freedom, and
with the best results. The patient improved daily, so that in a
short time no friction sound could be detected, unless when strong
pressure was made over the heart. She was finally dismissed in
good health, but with a feeble murmur heard at the apex of the
heart. Four months having elapsed, she was re-admitted, labour-
ing under a nervous attack, which had set in with delirium, and
was attended with excited action of the heart, but no sign of cai-
ditis could be discovered. This illness subsided in a few days, and
she left the hospital. In August, however, she returned; she had
been exposed to wet and cold, and rheumatic fever again showed

PERICARDITIS.

itself. Many of the articulations were swollen and painful, and
she also had pain in the heart, palpitation, and a great amount of
dyspnoea. Percussion showed increase of dulness over the heart,
while an intense 1'riction sound could be heard from the entire sur-
face of the organ, audible also over the whole anterior portion
of the chest, and in the left side posteriorly. The action of the
heart was violent, yet the pulsations did not resemble those of hy-
pertrophy. Pulse 108, jerking. The carotids had a strong and
visible pulsation. She was treated by a single bleeding, followed
by leeches to the cardiac region, while calomel and opium were
exhibited. Symptoms of great debility soon appeared, while the
friction sounds continued intense, and the praecordial distress was
but little abated. Under these circumstances she was ordered to
have a small number of leeches applied over the heart, while at
the same time we gave four ounces of wine. Next day there was
a distinct improvement in the general and local symptoms ; the
wine was continued, and it really seemed to act as a sedative on
the inflamed heart. In a few days the friction sounds wholly dis-
appeared, and her recovery was most satisfactory.

This case is strongly illustrative of the efficacy of wine in cer-
tain conditions of pericarditis, and it is important to observe, that
although on both occasions of the administration of stimulants
the general state of the patient was that of great debility, yet
there was no evidence of failure of the heart’s action, which was
excited and vigorous. Thus we find that there are at least two
cases of pericardial inflammation in which wine may be em-
ployed : one, that of uncomplicated disease, where the muscular
action of the heart is failing ; the other, a case of secondary, or
at least complicated pericarditis, with general debility and a ty-
phoid state, although no signs of cardiac weakness or paralysis
have so far appeared. Under such circumstances, then, even a vi-
gorous action of the heart , a jerking pulse, and an increased action of
the carotids, do not necessarily contra-indicate the use of wine ; nor
should the existence of the recent valvular murmurs of endocar-
ditis in such cases debar us from the use of the remedy. For we
often meet with the same general conditions now described, yet
without any affection of the serous covering, while the endocar-
dium is engaged, yet in which wine proves of the greatest service.

INFLAMMATION OF THE HEART.

If we consider that extensive series of cases in which peri-
carditis occurs, either as secondary to a general or essential dis-
ease, or as one of a group of local inflammations, we shall find
many cases in which wine may be used with liberality, even
though endocarditis be present. Excluding the complication
with ordinary rheumatic fever, we have to deal with pericarditis
in connexion with the diffuse inflammations, or the low erysipe-
latous state ; and again, in the pyogenic condition, as in the re-
markable cases described by Dr. E. M‘Dowela; in typhoid pneu-
monia ; and in the complication with delirium tremens from
excess, already alluded to, which is so often attended with a
typhus or typhoid fever. Many other cases might be speci-
fied, but enough has been said on the general question, flhere
are two cases, however, sufficiently common to deserve notice
here; one is the occurrence of the disease in the broken-down,
gouty constitution, and the other that in which pericarditis attacks
a heart in the earlier stages of fatty degeneration. Here the greatest
faults in practice, both of commission and omission, are often
seen ; the original disease is unsuspected, and the patient held to
have been in good health up to the time of the appearance of car-
ditis, when the lancet on the one hand, and the debarring of sti-
mulants on the other, at once reveal his condition, in most cases
when it is too late to mend it. In truth, it may be said that no
man is fit to treat general disease or local inflammation, espe-
cially its secondary forms, until he has conquered that fear of sti-
mulants which a long course of erroneous teaching has instilled
into his mind.

When the disease is only indicated by the signs of dry peri-
carditis, without fever or excitement of the heart, little moie is
necessary than the moderate use of local depletion ; but the
slightest appearance of excitement of the organ, even though un-
attended by any new sign of exocardial or endocardial disease,
should be at once met by an application of leeches, followed by
poulticing; in fact, the cardiac disease is to be treated precisely
as that of the joints. I have seldom used mercury in rheumatic

» See his Observations on Periostitis and Synovitis, Dublin Journal of Medical Sci-
ence, First Series, vol. iv., 1834.

PERICARDITIS.

pericarditis, where the symptoms were mild or wanting, and the
pnlse regular ; and it does not appear that the mere fact of com-
plication with dry pericarditis should lead to any special altera-
tion in our treatment of rheumatic fever. Great advantage will
be obtained from the use of poultices; they are particularly appli-
cable in this form, for the patient can bear their weight without
the suffering which they occasion in the more violent and idiopa-
thic disease.

Upon the merits of specific treatment in gouty or rheumatic
pericarditis, I can say little from my own experience, for I have
always been reluctant to adopt such a course. When either fever
or cardiac excitement exists, colchicum and bark should be used
with extreme caution, but the use of opium in free doses is not so
objectionable. Where great pain attends the disease, or that the
affection simulates angina pectoris, Dr. Latham strongly advocates
the use of opiuma.

Finally, it may happen not only in the secondary but the pri-
mary forms of this disease, that after the first violence of the at-
tack has been subdued, an effusion of liquid, more or less copious,
remains in the pericardium, and a condition is produced, analo-
gous to that of chronic empyema following on acute pleurisy.
In such a case we may employ mild mercurials, followed by the
internal and external use of the preparations of iodine, while the
action of the absorbents is assisted by the use of blisters or other
counter-irritants. In such a condition the operation of tapping
the pericardium, suggested by Senac and practised by Desault,
and in recent times by Schuh, may be found advisable. I have
no experience of this operation, yet although the difficulties and
risks attendant on it are probably greater than in empyema, we
cannot but hope that the puncture of the pericardium will, like that
of the pleura, be soon deprived of much of its danger and diffi-
culty1'.

* See Lectures on Clinical Medicine, &c., vol. i.

b In one case operated on by Dr. Schuh, of Vienna, the symptoms of hydrops-peri-
cardii were so severe as to threaten suffocation. A trochar was introduced between the
third and fourth ribs, very near to the edge of the sternum, and between it and the course
of the internal mammary artery. At first only a few drops of blood flowed out ; a small

INFLAMMATION OF THE HEART.

Treatment of Rheumatic Pericarditis.

When the true relation between rheumatic fever and the
different forms of carditis is considered, it will appear that the
activity of treatment necessary in idiopathic pericarditis is not
likely to be called for in the rheumatic variety. Whether the
doctrine of Bouillaud, that the heart in arthritis is to be looked
on as an additional articulation, be or be not adopted, we may
hold that its irritations are subject to the laws which govern the
affections of the joints. Like the articulations, we find it liable
to every shade and variety of irritation, from the slightest to
the most severe. Like them, too, we see it exhibiting gieat in-
constancy in the mode of succession of the different moibid pro-
cesses which attend its diseased state ; and lastly,, like many of the
individual joints in rheumatic fever, we may see it completely ex-
empted from any attack ; nor can we tell why this is so; why it
is that in one instance the heart escapes, and in another is attacked ;
nor why its irritations in some cases precede, in others follow, or
again, occur simultaneously with the inflammation of the joints.

Rheumatic pericarditis is, then, essentially one of the class of
secondary local diseases, and to its treatment we must apply those
maxims which guide us in the management of all such affections.
The importance and, indeed, the absolute necessity, of making a
daily examination of the heart while we are engaged in the treat-

bougie, passed along the canula, touched the great vessels, the pulsations of which were
distinctly felt. The operation was immediately repeated between the fourth and fifth
ribs when there flowed out slowly, and in a stream, a certain quantity of reddish serosity
(see’ Medico-Chirurgical Review, vol. xxxvii. p. 537). It is stated that relief followed
the operation, and that at the end of the third week the effusion into the pericardium had
disappeared. I am unable to ascertain whether this was a case of partial dropsy of the
pericardium or of effusion into the sac, resulting from pericarditis. The case has but little
value except with reference to the place of puncture. Two cases are given by Dr. Karn-
wagen, of Cronstadt, in which immediate relief followed the operation, and in one, a
permanent cure. In the latter case not less than three and a half pints of fluid were
drawn off, and during the operation air entered the cavity of the pericardium. In fi\ c
months the patient might be considered convalescent. (See British and Foreign Medua
Review, vol. xii. p. 250.) But neither of these cases appear satisfactory, and the lcngt i
of time between the operation and the final recovery is remarkable, if we assume that
an effusion had been removed by tapping. The diagnosis between mere dropsy of the
pleura and the pericardium is not always free from difficulty.

PERICARDITIS.

ment of a case of rheumatic fever has been insisted on by several
writers; but it cannot be too strongly impressed on the mind of
the practitioner that, valuable as the discovery of the signs of an
inflamed pericardium may be, it is not for these alone that he is
to look, but rather for the indications of excitement of the heart,
whether attended or not by the signs of exocardial or endocardial
disease. In other words, the sudden appearance, or the previous
and continued existence of increased action of the heart should
lead him not only to anticipate an attack of pericarditis, but should
make him adopt the precautionary measure of local depletion,
even though no friction sound or valvular murmur whatever be
present.

But further, it may be laid down that any abnormal or unusual
condition of the heart should awaken our suspicions, pending a
case of rheumatic fever or general rheumatic disease. The follow-
ing conditions may be specified among others : —

1. Excitement of the heart’s impulse, without any correspond-
ing state of the pulse, unattended by endocardial or exocardial
murmurs.

2. Excitement of the heart and pulse, attended with a ringing
sound of the ventricular contraction, appearing for the first time.

3. Sudden depression of the heart’s action in force or rapi-
dity. The lirst character may not be revealed by the pulse.

4. Sudden irregularity, without any other morbid sign.

5. Doubling of one of the sounds of the heart. This is not
uncommon ; it is much more frequent with respect to the second
sound, and I have observed it to disappear on the patient assuming
the erect position.

6. Prolongation of the first sound. This sign appears to de-
pend, not on any valvular affection, but on some altered condition
of muscular contraction.

It is hardly necessary to state that these conditions are not
always followed by well-developed symptoms or signs of pericar-
ditis or endocarditis, but that they indicate a manifest proclivity
to disease is certain, and we find them arising in a state of system
in which Cardiac disease is of common occurrence. We find them
often followed by the ordinary physical signs of the affection ;
and lastly, they are removable by local antiphlogistic treatment.

INFLAMMATION OF THE HEART.

In practice, we may adopt the following arrangement ol the
cases in which manifest physical signs appear: —

1. Dry pericarditis, without excitement of the heart or val-
vular murmur.

2. Dry pericarditis, with excitement of the heart, but yet
without valvular murmur.

3. Dry pericarditis, with excitement of the heart, and at-
tended with valvular murmur.

4. Pericarditis with excitement of the heart, attended by val-
vular murmur, and the signs of a progressive liquid effusion.

The order in which these cases are arranged will mark their
relative importance, and the degree of activity of treatment which
they will require.

Whether rheumatic pericarditis demands any special modifi-
cation of treatment is still an open question. The degree of acti-
vity of interference with the disease will, of course, depend not
only on the character of the attack, but on the period of the fever
in which it arises, and the strength and actual condition of the
patient. In the two last forms it will be generally right to use
mercury, pushed to salivation, not only with the view of control-
ling the pericarditis, but with the hope of preventing a chronic
disease of the valves. Opium is generally useful, but I have never
found that colchicum had any beneficial effect either in pericar-
ditis or rheumatic arthritis, while the inflammatory fever conti-
nued.

APPENDIX TO THE PRECEDING SECTION.

I. Physical Signs. — Among the rarer forms of these phenomena
is to be noticed the clicking sound described by Dr. Walshe. He
says: “Occasionally sounds are heard of peculiar clicking cha-
racter (only one or two with each beat of the heart), which are
only distinguishable at the time from modifications of the valvular
sounds by their non-synchronism with these, and by the extreme
irregularity of their occurrence. I have satisfactorily traced these
clicks to the pericardium, and further, in all probability, to the
separation (without attrition) of surfaces glued together with
exudation matter”a. Dr. Walshe further observes that he has

a Practical Treatise on Diseases of the Lungs and Heart, and of other Organs, 1851,
p. 230.

PERICARDITIS.

never detected this clicking sound, except in the site of the large
vessels.

This sign is not of common occurrence; its irregularity, and
want of correspondence with the valvular sounds, are sufficient to
prevent our mistaking it for that doubling of one of the sounds of
the heart (generally the second) which has been noticed in the
preceding pages.

II. Effects of Adhesion of the Pencardium upon the Heart. — At
the time when I made a communication to the Pathological So-
ciety of Dublin on this subject, and also when my observations
on it in the present work were written, I did not know that the
views which I ventured to put forward had already been
adopted and published by two distinguished writers, Dr. Barlow
and Dr. Chevers. In the Gulstonian Lecture for 1843, Dr. Bar-
low not only states that hypertrophy and dilatation do not of neces-
sity follow^ on obliteration of the sac, but that the latter condition
in most cases tends to produce atrophy of the heart11. Dr. Che-
vers’ paper will be found in the ninth volume of Guy’s Hospital
Reports. Dr. Walshe also observes that an atrophied state of the
heart appears sometimes to follow from the formation of false
membrane on its surfaceb.

The latest writer on the subject of adherent pericardium
is M. Forget. He believes not only that adhesions of the peri-
cardium must be considered as a serious pathological condition,
and one calculated to interfere with the heart’s action, but that its
existence can be determined by the careful consideration of the
history and actual phenomena of the case. He specifies (1) a
tumultuous and confined action of the heart, consequent on the
ordinary signs of pericarditis, or existing with other diseases, which
do not explain the disturbance of the circulation. (2) The small-
ness, inequality, and irregularity of the pulse, indicating the diffi-
culty experienced by the heart in performing a complete contrac-
tion. (3) The praecordial anxiety, dyspnoea, and tendency to
fainting, derivable from the preceding causes. (4) The usual con-
sequences of obstructed circulation, such as oedema, cyanosis, etc.
A general adhesion, according to him, may be diagnosticated,

* Medical Gazette, 1847.

b Op. Cit., p. 452.

INFLAMMATION OF THE HEART.

when, after the subsidence of the friction sound ol pericarditis,
the heart assumes a permanently tumultuous and irregular action.

I do not think that M. Forget has added much to our know-
ledge of this subject. A reference to the propositions attached to
my original memoir will show that the diagnosis of adhesion, from
studying the friction phenomena of the heart, was made long ago.
It is certain that in some cases of pericarditis a tranquil state of
the heart follows the organization of the lymph, while, in others,
a permanently irregular action may be established. But hi. Forget
has failed to show that this irregular and tumultuous action is at-
tributable to adhesion, for all the symptoms indicated by him
may occur independently of any preceding pericardial disease.
Again, after an attack of inflammation of so complex an organ
as the heart, there may be other causes for disturbance of its ac-
tion. The heart may be weakened ; it may be in the first stage ol
irritative hypertrophy; coagula may have formed in its cavities;
or a chronic endocarditis be in progress.

M. Forget depends on the coincidence of cessation of friction
sound, with increase of disturbance of the hearts action, as the
chief ground of diagnosis of adherent pericardium ; and he ob-
serves that the pulsations of the heart which depend on valvular
disease are more defined and less tumultuous, and are almost always
accompanied with bellows murmur, constituting the pathognomo-
nic signs of this condition, while that of adhesion is precisely the
absence of this sound. His statement, then, comes to this, that if,
after an attack of pericarditis, with friction phenomena, which
latter have disappeared, the heart’s action is tumultuous, the ab-
sence of valvular murmur should lead to the diagnosis of an ad-
herent pericardium*1.

From what has been now said the conclusion presses upon
us, that while on the one hand we may have an obliterated, or
nearly obliterated pericardium, without any ol the conditions ol
the heart indicated by M. Forget, so, on the other, the signs
which he has given are only conclusive, so far as the disappear-
ance of the friction phenomena are concerned.

Finally, the researches of Dr. Gairdner have led him to the con-

* Precis Theorique et Pratique des Maladies du Cceur. Par L. Forget, Strasbourg, 1851.

ENDOCARDITIS.

elusion that as the adherent pericardium, at first uncomplicated,
may in certain cases result in extreme hypertrophy of the heart,
yet that in other cases it may not only fail to produce this effect,
but appear altogether powerless in opposing the atrophy of the
heart resulting from chronic disease11.

ENDOCARDITIS.

The term endocarditis has been but recently introduced into
medicine, as designating the acute or chronic inflammation of the
lining membrane of the cavities of the heart, and more especially
its valvular apparatus. As in the case of gastro-enteritis, we find
that both the term and the description of the disease belong to the
physiological school, which refers so many affections to a sim-
ple inflammatory origin. But to every one who has studied the
history of medicine for the last half century, it is obvious that the
doctrines of that school were pushed too far, and that experience
has shown not only that we are unable to refer fevers and many
abdominal diseases to a gastro-enteritis, but that we cannot attri-
bute all the organic diseases of the valves to inflammation of the
1 endocardium. Still it is not to be denied that, for our know-
ledge of the great phenomena of gastro-enteritis and endocarditis
we owe everything to the physiological school, and, in gratitude
i for the benefits it has conferred on medicine, we may well ex-
cuse its disciples for having overstepped the limits of strict in-
duction.

Dr. Gairdner observes that “ the only view which seems to harmonize these con-
ditions is the supposition that the free motion of the heart within the pericardium is
required in health, not so much to meet the necessities of the circulation in its tranquil
and ordinary condition, as to provide for the contingency of excited action, and to give
i abundant scope for the smooth and painless motion of the heart under those circumstances
in which the habitual equilibrium of the circulation is disturbed. Such circumstances are of
daily occurrence ; in the healthy and vigorous, from superabundant use of bodily cxer-
: tion ; in the sick and debilitated, from the more sparing use of it ; in all, but especially
i in the nervous and excitable, from mental emotion, and a variety of minor causes. These
1 tcmPorary excitements are, however, to a great extent controllable ; and on this fact de-
pends, I believe, the practical application of these principles to the management of adhe-
rent pericardium, where it is known or suspected to exist.” — On the favourable Termi-
1 nations of Pericarditis, and especially in Adhesion of the Pericardium, with Cases illus-
trating its Secondary Effects on the Heart, by W. J. Gairdner, M. D. Edinburgh
Monthly Journal of Medical Science, 1851.

VOL. I.

INFLAMMATION OF THE HEAHT.

If, excluding the possible results of these lesions, we limit our
consideration simply to their earlier periods, in which the patho-
logical characters of acute irritation are developed, we shall at once
perceive the leading practical error of the followers of Broussais,
namely, that they took as their sole guide the visible, tangible
evidences of pathological anatomy, and did not recognise that
the same anatomical changes might occur in essentially different
states of the system, and have opposite relations to the constitu-
tional condition ; in one case the local disease being the cause of
the general disturbance ; in the other, truly its effect, though, when
developed, capable of a re-action on the economy.

Pathological science has shown that organic changes may
spring from an infinite variety of sources, and though with refe-
rence to the diseases of the white structures, inflammation appears
to be one of the causes most frequently met with, yet we cannot,
in the present state of our knowledge, reduce all valvular dis-
eases of the heart to the formula of an acute or a chronic inflam-
mation, and it will be better, practically, to consider chronic val-
vular disease as an affection sui generis, into the treatment of which
the question of existing inflammation does not necessarily enter;
and to place under the head of endocarditis only those cases in
which, with co-existing signs of local irritation and general systemic
disturbance, the signs of valvular lesion are more or less quickly
established.

Endocarditis may be observed as a primary idiopathic affec-
tion; as a secondary lesion in various constitutional maladies;
as a simple disease, or occurring in connexion with inflamma-
tion of the other cardiac structures; and lastly, it may be associ-
ated with analogous disease of other and even remote organs. The
general formula for its detection is the occurrence of symp-
toms of cardiac irritation, followed or accompanied by signs of
valvular lesion. If signs of pericarditis are present, the diagnosis
will be of endo-pericarditis ; if they are absent, of the simpler form
of the disease. In the complicated cases it may precede, follow,
or accompany the peripheral inflammation, and it may arise in
its most acute form in a heart whose valves are already far ad-
vanced in disease.

So imperfect is our knowledge, that we cannot say how far

ENDOCARDITIS.

the symptoms of general endocarditis differ from those of a par-
tial affection ; whether the disease in the right cavities presents
phenomena different from those of inflammation of the left auricle
and ventricle ; nor can we, if we exclude the signs of valvular
obstruction or erosion, declare whether the disease is attended with
any proper physical signs. For the polypoid concretions, the
false membranes spread over the cavities of the heart, the fissures,
fungosities, and other alterations of the endocardium, are as yet
incapable of being diagnosticated, their vital and physical effects
merging into the general group of phenomena which attend dis-
eases of the heart.

It is, then, by ascertaining the recent production of a valvular
lesion we discover an endocarditis, and even this may not be al-
ways conclusive, for we shall see that diseases of the valves, whose
origin is at least doubtful, are yet capable of a rapid and almost
sudden development.

In practice, however, the disease may be considered in the
following forms, which are given in the order of their frequency.
First, it may accompany, follow, or precede an attack of pericar-
ditis. Secondly, as occurring without pericarditis, when it is in
general manifested by symptoms of cardiac irritation, with signs
of recently-formed valvular disease. The absence of pericarditic
signs may be owing to the actual want of any peripheral irritation,
or to the obliteration of the sac by previous disease. Thirdly,
we find that, without any symptom which would lead to the sus-
picion that the heart was diseased, endocarditis may be insidiously
and silently developed in the course of rheumatic fever. Fourthly,
symptoms of irritation of the heart may occur in a case where
the organ has been previously diseased. These may be shown
either by an increase in the violence of the old, or in the produc-
tion of new symptoms; or lastly, by making manifest the signs of
former organic disease, which up to the period in question had
been unrecognised or wanting. Fifthly, symptoms of cardiac
irritation may be developed, unattended by any evidence of val-
vular lesion. This form is of rare occurrence, and I put it for-
ward with diffidence ; but I have seen cases which could not be
explained upon any hypothesis, except that of the absence of
murmur in endocarditis.

h 2

100

INFLAMMATION OF THE HEART.

These considerations apply only to the acute forms of the
disease; for the diagnosis of chronic endocarditis, especially where
we have not had an opportunity of studying its early stages, is
difficult, and the differential diagnosis between it and valvular
affections of another nature seems to be, in the present state of
our knowledge, quite impossible. Even where the origin of the
disease has been inflammatory, a great practical evil may aiise
from our continuing to view the case as one of chronic endocai-
ditis, for experience teaches that in many of such instances a tonic
and stimulating treatment will be attended with much happier
results than can be obtained by the antiphlogistic system.

Endocarditis being most frequently met with at the left side
of the heart, and its physical signs being developed principally at
the orifices, it follows that the chief grounds for its diagnosis
will be the recent production of mitral or aortic valvular murmur,
in cases where the local and general phenomena are indicative of
cardiac irritation.

To explain why it is that not only the physical signs of en-
docarditis, but also its more obvious pathological changes, are
confined to the valves, is difficult. The recent production of a
valvular murmur under general and local irritation may be held
to imply some mechanical change in the valve itself, and we know
that almost all the alterations or irregularities of the latter are
competent to produce murmur. The very early appearance of
this sign in acute endocarditis leads to the inquiry whether there
be other causes for the alteration of the valve besides its inflam-
matory thickening, or the deposition of lymph on its surface. It
is not improbable that those bundles of muscular fibres which
govern the action of the valves either participate in, or suffer from
the endocardial inflammation, and, as a result, that whether their
contractile force was augmented, as in spasm, or weakened, as in
inflammatory paralysis, the valve would be thrown into a new
and unnatural condition, and a murmur be developed even before
its disorganization had taken place*.

» I have specified paralysis as a possible condition, but in connexion with the early
development of murmur there is greater likelihood that more value is to be attached to
the opposite state. We may here refer to what has been already noticed in the typhoid
softening of the heart, in which there is nothing more remarkable than the absence of
valvular murmur. See Dublin Journal of Medical Science, First Series, vol. xiv.

ENDOCARDITIS.

101

If, however, dismissing these considerations, we admit that the
valves are more prone to inflammation than the membrane lining
the cavities, we are forced to inquire, what are the circumstances
which cause this difference. The structure of the valves, so far
as we know, does not differ from that of the endocardium ge-
nerally considered. This at least is true of the auriculo-ventri-
cular valves ; but when we consider the anatomical relations of
the membrane, we find that the endocardium of the cavities is in
contact with the red muscular tissue, while that of the valves is a
free serous structure. This, while it would not explain the greater
liability to disease of the valves, might throw some light on the
frequency of their chronic disorganizations.

It may be inquired whether those portions of the endocardium
in contact with red structure have, from that very circumstance,
any power of resisting inflammatory action, which is denied to
the valves; or again, whether, from a superior vitality, they are
endowed with greater energy, so as to rapidly organize and con-
vert into transparent structure such exudations as may be formed
upon them. When we come to speak of the markings of the ribs
on the pleura, after pleuro-pneumony, we shall find that, while
the serous membrane under the intercostal spaces may be, and
often is, in a state of transparency, those portions which corres-
pond to the ribs are opaque. In several cases I have found this
opacity to depend on the existence of adipose structure, proving
that the processes of transformation of lymph were different, ac-
cording as the membrane was in contact with muscular struc-
ture, on the one hand, or with fibrous tissue, on the other. Should
this analogical view possess any value, it may explain why the
transformation into cartilaginous, bony, or atheromatous matter,
is so often seen in the valves, and so rarely in the lining endo-
cardium.

As we have ventured into the field of speculation, one more in-
quiry or suggestion may be made. Is the greater liability of the
valves to inflammatory disease in any degree connected with their
relation to the tendinous filaments of the papillary muscles, which,
in a case of rheumatic fever, at least, may be supposed to be more
liable to disease than the remaining internal structures of the
heart ?

102

INFLAMMATION OF THE HEABT.

The symptoms of endocarditis are not yet fully ascertained or
defined, and it is doubtful ■whether its diagnosis will ever be
established with the same accuracy as that of pericarditis. Many
circumstances occur to make this diagnosis difficult. Of these we
may specify, first, the rarity of the disease in an uncomplicated
form ; second, the frequent co-existence of pericarditis ; and
thirdly, the general similarity of its constitutional symptoms with
those of the latter disease. In truth, we rarely meet with a case
of simple idiopathic endocarditis fit to be considered as a type of
the signs and symptoms of the disease. Such a case at least has
never occurred to me.

But yet we can often determine the existence of this affection,
always provided that, with a careful study of the history and
symptoms of the case, we combine the results of physical exami-
nation, for so closely do the symptoms of pericarditis and endo-
carditis resemble one another, that it is only by auscultation and
percussion that, in many cases at least, we can hope to distinguish
them.

Like pericarditis, this affection is often latent, causing little or
no distress to the patient, no irregularity of the heart, nor any other
symptom of irritation. This frequently occurs in rheumatic fever,
and the practitioner is often surprised by his patient showing
symptoms of valvular disease after an apparently perfect recovery
from the fever. Latent endocarditis may thus exist, and the dis-
ease be only recognised when it is no longer curable.

Dr. Hope is of opinion that endocarditis more frequently ex-
ists without pericarditis, than pericarditis without endocarditis.
I have come to a different conclusion. Doubtless, if we were to set
down all the cases of organic valvular murmur, even of a some-
what recent date, as examples of endocarditis, we should have
abundant instances of the apparently isolated disease. But when
we remember how commonly pericarditis is latent— so latent
that it scarcely disturbs the action of the heart — we should be re-
luctant to set down as simple endocarditis those cases in which a
pericarditis has never been recognised, especially when we re-
collect that there are other causes for valvular disease besides in-
flammation; and, on the other hand, it is to be noted that the
occurrence of acute pericarditis, without any present or subsequent

ENDOCARDITIS.

103

valvular murmur, is sufficiently familiar to the clinical observer.
In the present state of my opinion on this point I would place
the cases in the following order of frequency : —

1. Acute pericarditis with endocarditis.

2. Acute pericarditis without endocarditis.

3. Endocarditis without pericarditis.

In the cases where more prominent symptoms are developed,
it may be stated that there are the symptoms of pericarditis with-
out the signs, the direct physical diagnosis of endocarditis being
the recent development of valvular murmur. The patient often
complains of a load about his heart, with dull pain, and frequently
a sensation of heat. There is sometimes, too, a feeling as if the
heart was too large, and its pulsations are generally, whether re-
gular or irregular, of a greater force than could have been antici-
pated from the character of the pulse. In some cases we may
observe a ringing metallic sound attending the contraction, at least
in the early stages ; but this sign must not be relied on|unless in
connexion with other symptoms. Dr. Hope observes, that when
the circulation continues free, the action of the heart, stimulated
by the inflammatory irritation, becomes violent and abrupt, and
he holds that the increased extent over which it is perceptible is
proportionate to this violence, rather than to the inflammatory
turgescence of the organ, as Bouillaud has supposed. In this
opinion I entirely agree. In the more advanced stages we may
have those signs of greater cardiac suffering which occur towards
the close of fatal pericarditis, and I do not know any character by
which they differ from that class of phenomena. It is not impro-
bable that in some cases rupture of the chordae tendineae, as ob-
served by Dr. Law, takes place in the advanced stages. Two
causes concur to produce this terrible accident: one, the violence
of the heart’s action ; the other, the brittleness of the tendinous
chords themselves. Such an occurrence may be looked for, par-
ticularly when endocarditis attacks a previously hypertrophied
heart.

We have seen that the occurrence of a valvular murmur is the
most important physical indication of endocarditis, but we must
inquire whether it be so constant a sign as that its absence would

104

INFLAMMATION OF THE HEART.

imply the non-existence of any such disease. In certain forms of
pericarditis, where a serous or purulent secretion fills the sac, the
attrition murmur may not be produced ; and so in endocarditis it
may happen that, whether owing to the nature of the inflammatory
product, or to the fact that the valves escape alteration, there may
be, for a time at least, absence of valvular murmur. The follow-
ing case is worthy of careful study with reference to this ques-
tion : —

Case X. — Symptoms of Carditis , Valvular Murmur being only oc-
casionally developed ; absence of Friction Signs ; Death.

A woman, aged 30, having been six days ill, was admitted into
the Meath Hospital, with symptoms of fever, to which were added
palpitation, pain, and oppression in the region of the heart. She was
cupped on admission over the prsecordial region, with considera-
ble relief. On the next day her tongue was clean, and she had little
or no fever, but complained of pains in the bones. On applying
the hand over the region of the heart, a peculiar vibrating feeling
was communicated. The beatings of the heart were occasionally
regular, but with now and then along intermission, while at other
times they became irregular and rapid. During this latter state
the sounds were short, equal, and sharp, and closely resembled
those produced by a dog when rapidly lapping water. In this
condition there was no bellows murmur, but when the slower and
regular contractions supervened, a murmur, evidently endocardial,
was developed. There was no friction sound, nor any dulness
of the region of the heart. The patient was treated by local bleed-
ing, blistering, and the use of mercury, and for two days im-
proved, when she was suddenly attacked with general coldness of
the surface, rigidity, and slight delirium ; the pulse was feeble and
indistinct, with occasional long intermissions, its rate about 130.
The sounds had the same lapping character as before, with a dis-
tinct thrilling impulse ; there was still no friction, nor any endo-
cardial murmur.

Notwithstanding the use of antispasmodic and gently stimu-
lating medicines, and the mercurialization of the system, which
was effected by inunction, the symptoms continued, attended by

ENDOCARDITIS.

105

two new phenomena : one, the doubling of the second sound, and
the other, a continued sensation of sinking or faintness about the
heart. The double second sound was very feeble ; the stomach
became extremely irritable, and she complained of huskiness and
loss of voice. The throat was neither sore on pressure nor swol-
len ; the countenance became sharp and sunken, with a flush in
the cheeks, and she died on the twenty-first day of her illness, the
phenomena referable to the heart having continued up to her
death, without any change from the ninth day. No dissection was
obtained.

No one can doubt that this was an instance of carditis ; yet there
was no murmur produced, except at the earlier periods of the
case, and that, too, in a transitory manner, only perceived when
the heart was in an interval of comparative repose. Careful exa-
mination during life showed that there was no pericarditis, so that
the case may be taken as an example of endocarditis, in which
murmur disappeared long before death.

Let us recapitulate the facts of this case.

First, Alternations of slow and nearly regular action, attended
by murmur; with paroxysms of rapid irregular action, but with-
out any endocardial murmur.

Second, The latter character becoming constant.

Third, The feebleness of pulse, and doubling of the second
sound.

It is probable that the occurrence of endocarditis without
murmur, at least in its earlier stages, is of greater frequency than
we have hitherto believed ; and this may account for the appear-
ance and advance of a valvular murmur after the cure of pericar-
ditis. Such a case is not uncommon, and we may believe that,
although during the early periods of the disease there existed no
murmur, yet that endocarditis was silently forming, only to deve-
l°pe its signs when a certain amount of disorganization had oc-
curred. Should this view not be adopted, we would be forced to
admit, what seems improbable, that an endocarditis was developed
after the subsidence of the pericarditis, and this in a latent man-
ner, when the inflammatory condition had, to all appearance, passed
away.

It appears probable, that when from any cause the heart be-

106

INFLAMMATION OF THE HEART.

comes weakened, suck as occurs under the influence of the typhoid
state, or when a copious effusion exists in the pericardium, endo.
carditis may he present without murmur. This was, perhaps, the
case in that example of inflammation of the pulmonary valves
described by Dr. Graves, where the deposition of lymph on the
valves, which were but two in number, was so abundant. The
heart felt very soft, and lay collapsed ; its structure was pale, and
the pericardium was distended with straw-coloured fluid. There
was extensive hepatization of the right lunga.

Finally, we might expect that the ordinary signs of endocar-
ditis would be wanting in some cases of phlebitic disease ; and it
is possible that the small coagula, instead of being accumulated at
the orifices, are, as Bouillaud and others have described, entangled
among the fleshy columns. Here, however, although there is a
mechanical change within the heart, it may not be competent to
alter the currents of the blood in such a manner as to cause mur-
mur.

The next case illustrates the effect of acute endocarditis in
developing the signs of an old disease of the valves.

Case XI. — Dilatation and Hypertrophy of the Heart; Ossifica-
tion of the Mitral Valves, unattended by Murmur; Supervention
of Acute Endocarditis, developing a loud Murmur with the First
Sound.

A young man, who presented all the symptoms and signs of
chronic emphysema of the lung, entered the hospital, labouring
under great aggravation of his symptoms, induced by a recent
attack of bronchitis. So great was the inflammation of the lung
that the diaphragm showed signs of extensive depression, the
pulmonary sound extending for nearly two inches below the
ensiform cartilage. The heart was, of course, dislocated down-
wards, but no valvular murmur was discovered. After some time,
the bronchial effusion becoming very profuse, but with great de-
crease in the volume of the lung, the patient was ordered small
doses of turpentine, with tincture of lytta, which for a time pro-
duced some benefit. After a few days symptoms of fever were de-

* Clinical Medicine, First Edition, p. 904.

ENDOCARDITIS.

107

veloped, and the heart’s action became greatly and permanently
excited. A loud and hoarse murmur was now found to attend
the first sound ; it was most distinct over the region of the mitral
valve, and was not propagated into the arteries; there was no
friction sound, nor increase of dulness, and in this condition the
patient continued up to the time of his death, which took place in
a few days after the appearance of the cardiac murmur.

The symptoms and physical signs, taken in connexion with
the absence of all friction phenomena, led us to the diagnosis of
acute endocarditis. On dissection, the heart was found generally
dilated and hypertrophied ; the aortic and pulmonary valves were
of a deep red colour, and appeared softened and villous ; the left
auriculo-ventricular orifice was contracted by an extensive earthy
deposit, causing great irregularity on its ventricular aspect, but
forming a more regular deposit on the auricular side, the lining
endocardium was generally red, but no lymph was detected on
its surface.

The existence of considerable ossific deposits in the valves,
yet without the production of murmur, is a fact well known to
clinical observers. It is also ascertained that, for the production of
murmur, we must have not only valvular alteration, but a cer-
tain degree of force in the action of the heart, so that we are some-
times obliged to excite the organ, in order to develop the signs of
a disease which otherwise might be wanting. The excitement of
the heart, however, by an endocarditis, has not hitherto Jaeen
enumerated as among the causes for the production of a murmur
under these circumstances.

I rora what has been now said, we may draw the following
practical conclusions:

1. That endocarditis is a disease more frequently met with in
combination with pericarditis than as an isolated affection.

2. That it may arise simultaneousl}' with pericarditis, con-
stituting the true endo-pericarditis ; it may follow, or some-
times precede, the inflammation of the pericardium.

3. That the tendency to its production in rheumatic fever
must be considered less decided than that of pericarditis.

4. That its symptoms can scarcely be said to differ from those
of pericarditis.

108

INFLAMMATION OF THE HEART.

5. That there is no pathognomic sign of its existence.

6. That its diagnosis depends on the recent production of a
valvular murmur under circumstances indicative of cardiac irri-
tation, or the existence of special morbid states of the system,
which predisposes to inflammation of the heart.

7. That where the symptoms of pericarditis are developed,
but with absence of attrition sounds, or evidences of pericardial
effusion, we may make the diagnosis of endocarditis, especially
if there be the recent development of valvular murmur.

8. That the development of valvular murmur is not necessa-
rily a consequence of this disease, at least in its more acute
stages.

9. That the causes which in some rare cases of pericarditis
prevent the production of attrition sounds may be supposed also
to act in endocarditis. If the products of the inflammation be
of a homogenous nature, if they be purulent or merely sanguine-
ous, and if, moreover, they form no depositions on the valves, an
endocarditis may exist without the production of any valvular
murmur.

10. That the causes which tend to prevent valvular murmur,
even in extreme and chronic diseases of the valves, may also act,
in cases of acute endocarditis, in producing the same result. Of
these the two most likely to occur are, the weakness of the heart
itself, and the over-distention of its cavities with blood.

11. That endocarditis, in consequence of its effect in exciting
the muscular contractions of the heart, may actually develop a
murmur, part of which, at least, proceeds from former and latent
chronic disease.

12. That, although many cases of valvular disease evidently
spring from an endocarditis, yet that we are by no means justified
in attributing all valvular lesions to this cause, nor are we right in
considering and treating such cases, even when they become chro-
nic, as examples of chronic inflammation. It is true that the first
morbid changes may have been inflammatory; but this state
ceases, and is succeeded by new pathological conditions of depo-
sition and transformation of tissue.

13. That we cannot distinguish between endocarditis aflect-
ing the right side of the heart and that of the left cavities.

MYOCARDITIS.

109

14. That in cases of endocarditis passing into chronic and
progressive disease of the valves, we are not able by physical
signs to indicate the period when the inflammatory process
changes into one of mere transformation and deposition.

MYOCARDITIS.

Our knowledge of the effects of inflammation in altering the
muscular structure of the heart is still extremely limited ; and we
can easily understand why the pathological anatomy of myocar-
ditis should be so scantily illustrated, as compared with that of in-
flammation of the pericardium or lining membrane of the heart,
when we reflect that paralysis of muscular fibre appears to precede
its disorganization. If this paralysis affect any considerable por-
tion of the heart, death occurs before there is time for structural
change. It is only, then, in cases either of a local myocarditis,
or in those where the inflammatory action has concentrated itself
upon a point, that we can study with advantage the anatomical
character of the disease. Of myocarditis, independent of inflam-
mation of the pericardium or endocardium, it may be safely said
that we know nothing; at the same time we would not be justi-
fied in denying the possibility of its existence.

Myocarditis may be studied, first, as occurring in cases of the
preponderance of pericarditis, and next, in those where it appears
to spring from inflammation of the endocardium. From the very
limited acquaintance I possess of this condition, I would say that
it is most likely to be manifested in those cases in which, upon an
attack originally of the highest degree of acuity, a true chronic
inflammation has succeeded. This is especially true in the peri-
carditic cases ; and it appears probable that in such the external
layer of muscles is the first to exhibit perceptible anatomical
change. On the other hand, the examples of internal ulceration
of the heart may be supposed to arise in connexion with intense
endocardial inflammation.

Of the first of these I have seen a single instance : the patient,
a youth aged about 18, after being excited and overheated by vio-
lent gymnastic exercise, slept for several hours, lying on his left
side on the cold, damp grass; he awoke in a state of collapse,

110

INFLAMMATION OF THE HEART.

attended by pain in the prascordial region, so severe as to awake
him. More than a week elapsed before I was called to see him.
On my first visit he presented all the symptoms and signs of the
most violent pericarditis, and this condition, though somewhat
mitigated, remained until the patient’s death. No treatment which
was adopted seemed to have the slightest effect in controlling' the
disease. The patient suffered in an exaggerated form all the
miseries of a violent cardiac inflammation, and had the most in-
describable and persistent anguish. On dissection, the pericar-
dium contained a quantity of coffee-coloured, sanious fluid, mixed
with shreds of coagulable lymph. The serous membrane was co-
vered thickly with a dark-coloured, false membrane, so disposed
as to give a generally honeycombed appearance to the entire sur-
face of the heart. In numberless points ulcerative absorption of
the serous membrane had taken place, and corresponding to
these were well-defined depressions in the muscular structure of
two or three lines in depth, and of the same, or even a greater ex-
tent in diameter, evidently resulting from loss of substance in
the muscle itself. The whole heart had a livid, almost black
hue, which, however, decreased in intensity as we approached
the inner layers and columnse carnese. I have no record as to the
state of the endocardium.

The condition of the pericardium in this case was precisely
similar to that which we observe in protracted cases of empyema
and pneumothorax, where perforations of the serous membrane,
not, as in the first instance, occurring from within outwards, but
from without inwards, are found to exist, constituting a new order
of secondary fistulse.

This case, clearly an example of general carditis, would have
been placed by Testa under his general head of Gangrene and Rup-
ture of the Heart ( Cancrena e Rottura del Cuore). According
to him, the heart, like all other organs subject to local inflamma-
tion, may be attacked with the most violent form of the disease,
eventuating in ulceration and gangrene, examples of which he
points out in the works of some of the older authors. This writer,
however, dwells especially on the gangrenous or ulcerative dis-
ease of the heart, which proceeds from internal inflammation.
Thus he describes a case in which a careful examination of the

MYOCARDITIS.

Ill

right cavities, the ascending cava, and the pulmonary artery,
showed a flocculent surface, as if the membrane was putrified.
This was tinted by a black sanies, similar to that seen on the sur-
face of gangrenous sloughs. In another case he describes the ul-
cerative process developed in the left ventricle, the carditis in
this instance being apparently induced by long-continued and
violent exertions. He gives a third case, which was probably
one of endo-myocarditis, associated with a dissecting aneurism of
the aorta. Death took place by rupture into the pericardial sac.
A Bolognese lady, aged 28, of an ardent temperament and strong
passions, was condemned to an imprisonment of fifteen years.
The severity of her incarceration and mental excitement induced
an inflammatory fever. Some months afterwards she was attacked
with an internal sensation of cardiac suffering, attended with
lancinating pain, with which she was at times, as it were, trans-
fixed. This principally affected her during the act of eating, so
that she frequently had to remove the unmasticated food from
her mouth. She suffered from most violent palpitations, so severe
that she frequently thought her last moments had arrived. Not-
withstanding these sufferings, the patient lived for more than ayear.
During the last three months she had cephalalgia and vertigo.
The face was pallid and livid. She had also acute, though fuga-
cious pains in the chest, shoulders, arms, and loins. These symp-
toms were mitigated on the occurrence of a periodical epistaxis,
which took place every fifteen days. Bleeding from the foot and
other evacuations had also an alleviating influence. Her death
was sudden : while she was in the act of speaking to her compa-
nions, she fell to the ground, and ceased to exist.

On dissection, the lungs were found to be healthy. The peri-
cardium contained not less than two pounds of blood ; and the
heart, which was of a natural size, was flabby, and covered by a
thick layer of fat. The anterior auricle was distended with blood,
and greatly attenuated, while the posterior auricle was small and
contracted. The anterior ventricle presented thickened and firm
■walls ; it was without blood, but covered with deep ulcerations.
The semilunar valves were for the most part destroyed by a vast
ulceration, extending nearly to the arch of the aorta, and beyond
this point to the bifurcation of the vessel in the abdomen ; the lin-

112

INFLAMMATION OF THE HEART.

ing membrane was of the brightest red colour; a large rent of
the artery had taken place at its orifice.

In this case we have an example of a chronic ulcerative en-
docarditis and an aortitis. The fatal effusion of blood took place
by the extension of the ulcerative process which had been estab-
lished at the orifice of the aorta.

Such cases, however, are in these climates of rare occurrence,
and the example now given from Testa is chiefly valuable as il-
lustrating the greater violence of local inflammation which is met
with in the warmer European climates, where, doubtless, both es-
sential and local diseases are often developed in their highest de-
gree of intensity. It is one of these rare cases, the principal va-
lue of which, in a practical point of view is, that it exhibits the
extreme degree of lesions which are generally met with in a miti-
gated form.

According to Hasse, the existence of a general carditis, where
all these structures are engaged, must be considered as a rare
occurrence, at least when we speak of the disease in its highest
degree. But he considers that the coincidence of the three forms
in a minor degree is much more common, and he believes that
none of the forms can occur in its highest intensity, without im-
plicating the other textures of the heart. We are as yet but little
acquainted with the pathological appearances of inflammation of
muscular tissue, but serous infiltration, purulent softening, and
abscess, appear to be the leading marks of the different stages of
myocarditis. It is further stated by Hasse that myocarditis ge-
nerally attacks the left ventricle, and my experience of the acous-
tic phenomena of severe pericarditis appears to confirm this state-
ment, as we commonly find a failure of the first or systolic sound
in the advanced stages of the disease. It is probable that in such
cases both ventricles are engaged, but especially the left.

Abscess of the walls of the heart may be occasionally met
with; but we must not confound a true phlegmonous abscess with
the purulent deposits to which, in common with other organs,
the heart is liable in cases of plilebitic disease. Professor Smith
has met with some instances of apparently true inflammatory ab-
scess of the heart; and a case is given by Dr. Graves, in which, in
addition to the usual symptoms of hypertrophy of the heart with

MYOCARDITIS.

113

valvular disease, the patient suffered from violent pain in the re-
gion of the heart, darting over the chest, and which, towards the
close of the case, became excruciating. His death took place
suddenly. The heart was found greatly enlarged, and the peri-
cardial sac was obliterated by adhesions, which, except at the
apex, were easily broken down. In the latter situation they were
strong and firm, and in the attempt to break them a rent was
made in the substance of the heart, through which more than
two ounces of purulent matter escaped. This rent communicated
with a cavity in the substance of the heart, capable of containing
more than two ounces, and lined with a firm cyst. The semilunar
valves were greatly ossifieda.

This case may have been originally one of general carditis,
ending in the quadruple lesion of valvular disease, hypertrophy,
abscess, and obliteration of the pericardium. How far the exist-
ence of the abscess may account for the character of the pain is
worthy of inquiry. We not unfrequently observe pain in the or-
dinary cases of enlarged heart and permanent patency of the aortic
valves, but in this case the violent, persisting, and paroxysmal
character of the pain seems to indicate that it proceeded from
some special cause.

We may, in the present state of our knowledge, arrange the
results of myocarditis as follows :

1. An injected state of the cellular structure, followed by se-
rous or sero-sanguinolent infiltration, and diminished consistence
of the muscular fibre. (Hasse.)

2. Lardaceous transformation of the effusion, giving a homo-
geneous appearance to the structures ; the muscular fibres, however,
retaining their texture and form. (Hasse ; Gluge.)

3. Interstitial suppuration, analogous to that in the advanced
stages of pneumonia.

4. Abscess in the muscular structure of the heart.

5. Superficial ulcerations, presenting a crebriform appearance.
These may be seen on the outer surface of the heart, in connex-
ion with severe pericarditis, as in the case which I have detailed,

* Clinical Medicine, Lecture xxxviii.

VOL. I.

114

INFLAMMATION OF THE HEART.

or on the inner surface, when there is a complication with intense
endocarditis.

We have no means of diagnosticating any of the forms of sup-
purative myocarditis11.

There are other forms of disease, however, which, if not in
every case to be attributed to carditis, appear often related to it.
Of these, rupture of the valves, the occurrence of adherent coa-
gula, purulent cysts in the heart, and partial aneurism of the
ventricles, may be considered as examples.

I have never met with an instance of rupture of the chordae
tendineae which could be attributed to acute endocarditis, but there
is nothing impossible in such an occurrence. Hasse states, that in
a few instances he has found the semilunar valves of the aorta and
the pulmonary artery inflamed, and torn into shreds and filaments,
which, covered with little wedge-shaped pellets of coagulum and
effused matter, floated in the arterial tube in the direction of the cur-
rent of the bloodb. The same author speaks of the rupture of one
or more of the papillary tendons, and observes that this accident is
more common at the mitral valve. We are not, however, to at-
tribute all cases of rupture of these chords to an acute inflam-
mation, as doubtless the lesion more often results from the brittle-
ness of the chords, which may be one of those changes occurring
as a sequence of inflammation, though not with an actually existing
inflammatory state.

Carditic Polypi. — On the occurrence of this form of disease
pathological investigation has as yet thrown but a doubtful light;
and, though according to Rokitansky, Bouillaud, and others, there
is reason to believe that large polypi may result from carditis, yet
the cases in which coagulation of blood in the cavities of the heart
originates in a different manner are far more numerous than those
in which it can be attributed to the effect of inflammation of the

a A case of purulent softening of the heart, by Dr. Salter, is quoted by Hasse.
Sec Dr. Swainc’s translation, p. 120. Dr. Swaine, in a note refers to a case by Mr.
Stanley, Medico- Chirurgical Transactions, 1816, and to another quoted by Dr. Bennett,
British and Foreign Medical Review, No. xxxix., which is taken from the Bulletin de
l’Acaddmie Royale de Medccine, Avril, 1843.

» Op. Cit., p. 130.

MYOCARDITIS.

115

endocardium. But while we believe that carditic polypi or coagu-
lations are not so frequent as Rokitansky and especially Bouillaud,
have taught, pathological analogy forbids us to deny that these
polypi may result from carditis.

It is now some years since Dr. Graves and I published a case
of very extensive arteritis affecting the right common iliac artery,
and the arteries of the corresponding extremity. The patient had
been attacked, about two months before his admission, with alter-
nating sensations of burning heat in the toes of the right foot, fol-
lowed by pain, coldness, and complete loss of sensation in the foot.
In this condition he remained until the day of his admission, on
which day the pain suddenly extended to the calf of the leg, and
became intolerable, attended with nearly complete loss of power
of the entire extremity. During the night the pain extended to
the thigh. Next day the temperature of the limb was found to
be about 58°. From the middle of the thigh to the toes, all sen-
sation was lost; and, excepting that he could rotate the thigh
slightly, there was no other voluntary motion of the limb. The
femoral artery was felt to be hardened, and apparently enlarged ;
it was painful on pressure, and without pulsation.

Gangrenous action soon took place, speedily followed by death.
The right common iliac artery was livid, and distended by a clot,
which stretched into the external and internal iliacs, and all their
branches, downwards, as far as they could be traced. The lining
membrane of the vessel was red and villous, and in some portions
the clot was separated from the vessel by a layer of dark-coloured
puriform matter.

This case admits of more than one interpretation, but is inte-
resting as being an instance of coagula in connexion with an arte-
ritis8.

APPENDIX TO THE PRECEDING CHAPTER.

There are two subjects which may be noticed here, viz., the
occasional doubling of one of the sounds of the heart, and the
existence of purulent cysts within the cavities of that organ.

“ Report of the Meath Hospital, Dublin Hospital Reports, vol. v.

i 2

116

INFLAMMATION OF THE HEART.

DOUBLING OF ONE OF THE SOUNDS OF THE HEART.

Among the physical signs of derangement of the action of
the heart, I know of none more obscure in its nature than the
doubling of one of the sounds. It is as if the sound, in place of
being single, was divided into two sounds, in some cases similar
in tone and duration, in others differing in both these qualities.
This sign seems to affect the left more frequently than the right
side of the heart, and in the majority of cases occurs in connex-
ion with the second rather than with the first sound. We are
not, I believe, as yet in a position to explain the nature of this
phenomenon ; but it appears more frequently to be connected with
functional than with organic or inflammatory diseases of the heart.
Analogy, however, would lead us to expect that this condi-
tion, like many other symptoms of functional affections, might
be met with in connexion with inflammation, just as pain, irre-
gularity, and palpitation are common to both conditions ; and I
have occasionally observed the sign in question in connexion
with symptoms of endocarditis. Of this the following is an ex-
ample :

Case XII. — Symptoms of Acute Endocarditis; Doubling of the

Second sound.

A woman, aged 28, was admitted into the Meath Hospital, in
January, 1840. She had enjoyed good health until a few days
before admission, when she was attacked with rigors, prostra-
tion of strength, loss of appetite, and extreme thirst. Pain and
palpitation of the heart set in, and she referred all her sufferings
to that organ. No morbid physical sign could be discovered.
Three days afterwards the pulse was 130, weak and intermitting,
while the action of the heart was violent. A slight bellows mur-
mur accompanied the first sound; she complained of a feeling as
if her heart teas tearing out. Two days afterwards, the following
changes were found to have occurred : the bellows murmur had
disappeared, and the second sound had evidently become double,
and was much louder than the first: the action of the heart con-
tinued violent. In this state she continued for ten days, the heart

DOUBLING OF ONE OF THE SOUNDS.

117

all the time acting with great violence, the pulse rapid, and ex-
ceedingly feeble. She soon afterwards died.

In this case the dissection was not satisfactory, as the body was
removed to a public dissecting-room, where the arterial system
was injected from the aorta for the purpose of demonstration. The
heart was not enlarged, but the wax injection had filled the left
ventricle, in all probability by lacerating the valves. The lining
membrane of the heart was of a deep red, with a purplish hue.
The stomach was vascular, and presented the hour-glass con-
traction.

That this case was an example of carditis no doubt can be
entertained. The patient had been in the enjoyment of good
health up to the period of the first rigor, and the absence of signs
of valvular disease on her first examination showed that the heart
had been previously healthy. The pain, the cardiac anguish, the
rapid and irregular pulse, the violent and jerking action of the
heart, if taken in connexion with the absence of pericarditic
signs, and the peculiar valvular phenomena, all indicate that en-
docarditis of a severe kind existed. The cessation of the mitral
murmur, followed by the doubling of the second sound, is worthy
of especial notice.

This patient was treated by local bleeding, counter-irritation,
and mercury. Ptyalism was produced, but without any beneficial
effect on the symptoms.

Case XIII. — Rheumatic Endocarditis ; Distinct doubling of the

Second sound.

A young man, aged 16, was attacked with acute arthritis,
in the month of August, 1838: his health had been previously
excellent. On the day of his first attack he suffered from vio-
lent palpitations. He was admitted on the eighth day of his
illness, with the usual symptoms of acute rheumatism affecting
many of the joints. The pulse was 90, full and thrilling, with
this form of irregularity — that after twelve or fourteen strong and
full beats, three or four small, quick, and feeble pulsations would
succeed. The impulse of the heart was strong, and the first sound
was accompanied by the slightest possible bellows murmur. He

118

INFLAMMATION OF THE HEAKT.

was treated by the application of leeches to the inflamed joints,
and to the cardiac region, with great relief; but in a few days the
symptoms returned, the heart’s action intermitted after every
third or fourth beat: the first sound presented a distinct bellows
murmur, while the second was replaced by two short, sharp
sounds. Palpitations and pain were absent. By the use of
leeches, counter-irritation, and digitalis, the cardiac symptoms
were removed, and the patient was discharged free from any
morbid state, except that the first sound of the heart was attended
by a very indistinct murmur. This patient was admitted seven
months subsequently. The rheumatic disease had returned, and
produced all the usual effects of chronic arthritis. The heart’s
action was irregular, with a feeble impulse, and remarkably weak
first sound, which had a dull, muffled character, with an occa-
sional faint bellows murmur. The character of the irregularity
was such, that the heart would occasionally beat for upwards
of a minute without any intermission ; then a distinct intermis-
sion would occur, followed by several quick, short pulsations.
Although occasionally suffering from palpitation, he did not com-
plain of any uneasiness about the heart.

Case XIV. — Arthritis; Cardiac complication ; Bellows murmur
accompanying the First sound; doubling of the Second sound
while the patient remained in the horizontal position.

A woman, astat. 30, was admitted to the Meath Hospital, Oct.
31, 1839, labouring under an acute arthritic affection. At the
time of her admission she was much prostrated, and suffered se-
verely from pain in several of the large joints. Her pidse was
140, weak and intermittent. A loud bellows murmur accompanied
the first sound of the heart, the impulse of which was abrupt and
jerking. She continued in this condition for several days, no
change being observed in the physical signs, as above described,
until the 6th of November, when, on examining the heart, its
second sound was found to be distinctly doubled ; but the mur-
mur still remained confined to the first sound. No improvement
was at this time observed in her symptoms. The arthritic af-
fection continued severe, with profuse perspirations and great
nervous depression. In a few days, however, a marked change

PURULENT CYSTS OF THE HEART.

119

for the better took place, and this not only in the symptoms, but
also in the physical signs. The impulse of the heart returned to
its natural standard. The murmur decreased both as to loudness
and prolongation, and the doubling of the second sound could
only be distinguished when she assumed the horizontal position.
From this period she gradually improved, and on examination of
her heart, a few days prior to her leaving hospital, we could only
detect the murmur with the first sound when she was in the re-
cumbent position ; the second sound was perfectly normal.

This case exemplifies the double second sound existing in
endocarditis, and also its cessation when the patient was erect.

The doubling of one of the sounds of the heart cannot be
considered as any special sign of any of the forms of carditis, for
we meet it in cases of a different kind. It may be observed in
nervous and chlorotic patients ; and I have lately found it in the
case of a man very far advanced in life, who was labouring under
the symptoms of peripneumonia notha. It is, then, clearly only
an indication of a special form of disturbance of the action of the
heart. What its origin may be is difficult to declare ; but that it
is to be attributed to valvular rather than to muscular action ap-
pears more than probable. The greater frequency of its occur-
rence with the second sound, and the fact recorded in the last
case, of its disappearance in the erect position, seem to point to
this conclusion. I do not know of any condition which would be
adequate to explain the occurrence in question, except a want
of synchronism in the action of the pulmonary and systemic por-
tions of the heart.

PURULENT CYSTS OF THE HEART.

In giving the results of my observations on this affection, I
am desirous that it should not be believed that I am satisfied as
to its nature, especially as to its being one of the results of cardi-
tis. The truth is, that great obscurity still hangs over the his-
tory of this affection, and it is here introduced rather as a matter
of convenience than with any desire to promulgate the doctrine
that carditis may produce this peculiar lesion.

It is found that in certain cases which are examples of acute
or chronic disease of organs and structures often remote from the

120

INFLAMMATION OF THE HEART.

heart, the cavities of this organ present cysts, as it were entangled
in its fleshy columns, and exhibiting various degrees of adhesion
to its walls. Their size is various, and they generally contain a
purulent fluid, which in some cases appears to be undergoing a
process of transformation in which atheromatous or calcareous
matter appears. They are to be met with both in all the cavities
of the heart, and may be found in hearts otherwise healthy, at
least so far as the endocardium is concerned, or exist with various
forms of chronic disease, and even with purulent deposits, in the
substance of the heart itself. (See Cruveilhier.)

Of the nature of this affection we cannot yet speak with
any decision. We may, however, say, that it is not a result of
ordinary endocarditis, inasmuch as the necessary conditions of
this affection are often absent; and that the disease appears to
want the symptoms and signs of ordinary inflammation of the
heart. We will not here describe the different opinions put for-
ward on the subject, but simply indicate a few of the most im-
portant. Three distinct doctrines are entertained on the point:

1. That they result from coagula produced by inflammation,
which themselves take on a suppurative action. They may thus
be considered as remotely the effects of endocarditis.

2. That coagula being formed, from whatever cause, they be-
come purulent, owing to the existence of a pyogenic diathesis.

3. That they may be the result of a true cardiac phlebitis.

Many circumstances lead to the opinion that it is to the two

latter causes that we should refer this peculiar condition: at the
same time it must be confessed that the entire subject of the con-
version of fibrine into pus is involved in extreme obscurity.

Even if it could be admitted that simple coagulation of blood
was a common effect of endocarditis, there would be a great pro-
bability against the coagulum becoming the nidus of a purulent
deposit. If we refer to the case of aneurism, in which successive
layers of fibrinous coagula are formed, how rarely does it happen
that they exhibit any purulent change. May not some analogy
be supposed to exist between the coagulum found in the heart,
and continuing after its exciting cause has been removed, and
that met with in a large aneurismal sac?

A greater degree of probability exists in favour of the second

PURULENT CYSTS OF THE HEART.

121

supposition : — that a coagulum having been formed, either an-
terior to or consequent upon a pyogenic state, it becomes, in vir-
tue of its feeble organization, or the action of some elective affinity,
the nidus of a purulent deposit. Something analogous to this is
seen in cases of arteritis, as already described ; and in other in-
stances, where the coagulum has been found not only surrounded
by a purulent layer, but actually containing pus in its very sub-
stance.

Without denying that purulent cysts of the heart may in some
cases admit of this explanation, Professor Smith inclines to the be-
lief that they may result from a cardiac phlebitis. It is certain that
they have been often found in cases of phlebitic disease, and as in
such cases organ after organ seems to assume this special form of
disease, there is no reason why there should not be a cardiac
as well as a renal, hepatic, pulmonary, or uterine phlebitis. It
is true that in many cases of venous inflammation a great num-
ber of organs become affected, but this is by no means constant;
and the frequent exemption of this or that structure or organ in-
clines us strongly to the belief that the existence of purulent mat-
ter in particular situations is owing less to any general purulent
state of the blood than to the production of a specific irritation in
the organs so affected. We are still, however, in great want of
further researches on the subject, but Professor Smiths views are
strengthened by the fact already noticed, that in some of these
cases of purulent cysts in the cavities, deposits of pus are to be
found in the substance of the heart itself.

The fact of these purulent collections being found encysted
would seem to connect them with the process of chronic disease.
Of this the following case is an illustration.

Case XV. — Purulent Cysts in both Ventricles: Protracted symptoms
of Phlebitic Disease.

An Italian, after having for a length of time abstained from in-
toxicating liquors, had indulged to great excess in their use, and
was admitted into the Meath Hospital, labouring under a compli-
cation of alarming symptoms. He had a low irritative fever,
attended by symptoms of delirium tremens, and a feeble pulse,

122

INFLAMMATION OF THE HEART.

generally ranging between 130 and 150, and it is remarkable
that this quickness of pulse continued to the period of his death,
which happened two months after his admission. On one occa-
sion it fell to 120, but soon resumed its former rate. In addition to
these symptoms the left thigh and leg were extensively swollen,
presenting the general appearance of the second stage of phleg-
masia dolens. The right lung exhibited the signs of pneumonia
in its inferior portion, with bronchial respiration at the root of the
lung, and friction sounds laterally and anteriorly. These signs, as
well as the crepitating rale, remained singularly persistent, not-
withstanding the employment of such general and local remedies
as the state of the patient would justify. The fever passed into
a species of hectic, and the patient died in a condition of extreme
anaemia.

The abdominal cava was found to contain a long coagulum ad-
herent to the vein ; its surface was rough, and on its being detached
we found the corresponding portion of the vein red and villous. In
the femoral vein was a similar coagulum, and the artery, vein, and
nerve were agglutinated. The saphena was obliterated, and felt
like a hard cord, and this obliteration extended as far as the .vein
could be traced. In the right ventricle we found some dark-co-
loured coagula and creamy matter, but the endocardium showed
no sign of inflammation. A number of small, white tumours,
which proved to be cysts containing pus, were found between the
columnse carncse. The left ventricle, also, exhibited these cyst?,
three of which were of great size, and adhered very slightly to
the parietes of the heart. The inferior lobe of the right lung was
solid, and, when cut, very nearly resembled red granite. There
was no abscess, but purulent matter, exactly similar to that in the
heart, could be squeezed from every part of the cut surface. In
the upper lobe of this lung, as also in the left lung, numerous iso-
lated deposits of the same nature existed, the intervening tissue
being healthy. The liver, spleen, and kidney, the joints, and
voluntary muscles, exhibited no purulent depositsa.

Mr. O’Ferrall has, on two occasions, exhibited specimens of
this disease to the Pathological Society. In one of these cases

» See the Transactions of the Pathological Society of Dublin, December, 1842.

PURULENT CYSTS OF THE HEART.

123

the patient, an adult male, was admitted into St. Vincent’s Hospital,
labouring under an attack of pleuritis,but also presenting symptoms
of hypertrophy of the heart, with hcemoptysis, anasarca, ascites, and
albuminous urine. There was nothing in the phenomena of the
heart beyond the ordinary signs of hypertrophy. He died five
months after his admission. On dissection, the organ was found
greatly enlarged : it contained numerous cysts, generally of the
size of a bean, while some were as large as a walnut; they were
attached to the internal surface of the ventricles as well as of the
auricles ; their contents were various, some being filled with puru-
lent matter, others containing a substance closely resembling the
fibrine of blood, while in a third class the contents seemed inter-
mediate between fibrine and purulent matter. One of the cysts
contained nearly two drachms of pus, and their internal surface
had a villous appearance. A gangrenous cavity existed in the
upper portion of one lung, while a large portion of the spleen
showed a deposit of a yellowish-white substance, similar to the
fibrine of blood.

In another case, observed by Mr. O’Ferrall, the specimen was
taken from the body of a boy aged 16, who had laboured under
disease of the heart and kidneys. The urine was pale, albumi-
nous, and of the specific gravity TOIO. The region of the heart
was dull, and there existed strong impulse, and a bellows murmur.
On dissection, the kidneys were found to exhibit Bright’s disease
in a certain degree. In the cavities of the heart several cysts,
containing puriform matter, were found in the left auricle, and en-
gaged among the fleshy columns of the right ventricle.

As to the nature and causes of these purulent cysts, it will
be sufficient to say, that two opposite opinions have been de-
fended by pathologists. One is that adopted by Mr. O’Ferrall,
who holds them to be examples of purulent softening of clots pre-
viously formed ; and the other that of Bouillaud, who considers
the coagulation ol the blood as the second step in the process. He
believes that pus, carried into the cavities of the heart, there acts
in producing coagulation of the blood. There is strong reason
for adopting Mr. OFerrall’s view, at least in certain cases, for
the instances he has brought forward of cysts containing a va-
riety of contents, which were of the nature of decomposed blood

124

INFLAMMATION OF THE HEART.

in various stages, are most important. Still, however, the general
history of these cysts is open to further investigation.

We are not yet in a position to declare the diagnosis of this
lesion. In one of Mr. O’Ferrall’s cases there appeared no physical
sign of disease of the heart of any special kind; and in another,
where organic disease affecting the valves existed, the signs pre-
sented no unusual character. It is greatly to oe doubted whether
we have any means of detecting an ordinary coagulum of blood
in the heart, but we are not to despair of yet discovering some
signs indicative of this accident.

The following case is worthy of being recorded. A young
man, who had been previously in good health, was attacked
with the symptoms of malignant cholera, during the last epide-
mic of that disease in Dublin. Within a very few hours after
collapse had been established, a loud bellows murmur was dis-
covered at the upper and middle sternal region. This continued
up to the time of death ; and on dissection a large coagulum was
found in the left ventricle, stretching upwards, and extending
through the aortic orifice into the arch of the aorta. The valves
of the heart and its walls were found perfectly healthy, so that
there can be no reasonable doubt that the bellows murmur was of
recent production, and was owing to the intei ference of this re-
markable coagulum with the proper action of the aortic valvesa.

The occurrence of these purulent cysts in the cavities of the
heart constitutes one of the most singular circumstances in the
whole range of cardiac pathology. In the dearth of information
on the subject, it will be desirable to state generally such observa-
tions as have been made upon it in Dublin. We find, that as yet
no satisfactory explanation has been given as to the formation of
these cysts, at least so far as the mechanism of the process is con-
cerned. How a cyst, which in some cases appears to have no
organic connexion with the endocardium, may be formed within
the heart is still a matter of pure conjecture. We find such cysts
entangled with the fleshy columns, yet without any connecting tis-
sue or structure ; while in other cases there appears to be an ad-

* Owing to the kindness of Mr. Rynd, under whose care this patient had been, I was
enabled to exhibit the post mortem appearances to the Pathological Society. The case is
one full of interest.

PURULENT CYSTS OF THE HEART.

125

hesion or slight organic connexion. Their contents are various.
They may present decomposed blood in various stages, as Mr.
O’Ferrall has shown. They may be filled with true pus, as in
the case I have given, and also in the example recorded by Dr.
Bigger8, in which the patient died of phthisis pulmonalis with-
out ever having presented any symptom of cardiac disease. The
cysts in this case were numerous, each about the size of a small
bean, some of them merely inserted between the carneae column®,
others imbedded in the muscular substance. Lastly, as in a re-
markable specimen preserved in the Museum of the Richmond
Hospital, they may exhibit the cretaceous transformation of their
contents. The cysts exhibit little, if any traces of organization,
and so far as we know the disease, appear to affect both sides of
the heart indifferently.

It is remarkable that while Hasseb declares that the purulent
coagula of the heart occur oftenest at the left side, yet that Forget
comes to the opposite conclusion0; and so far as the nature of the
disease is concerned, we can form no other opinion, but that it is
in some way connected with the pyogenic state. That it cannot
be considered as one of the results of simple endocarditis is certain ;
and we know of no means by which its existence can be deter-
mined. A remarkable case is given by Forget, in which the cysts
were confined to the left ventricle. The lungs contained many'
tuberculous ulcerations. In the case which I have recorded, and
in the examples given by Mr. O’Ferrall, the cysts existed in both
ventricles, a circumstance which goes to strengthen the opinion of
Forget, that in the case which he has recorded, the limitation of
the disease to the left ventricle was owing to the fact that the
lung had supplied the purulent matter.

Before we conclude these general observations on carditic
disease, we must allude to two points of importance in practical
medicine: one of these is the innocuousness, even for many years,

a See the Transactions of the Pathological Society of Dublin, 1838, Dublin Journal
of Medical Science, First Series, vol. xv.

b Anatomical Description of the Diseases of Circulation and Respiration, by C. E.
Hasse, Dr. Swaine’s translation, London, 1846, p. 156.

c Precis Tlieorique et pratique des Maladies du Coeur, Strasburgh, 1 849.

12G

INFLAMMATION OF THE HEART.

of valvular disease sufficient to afford prominent and permanent
physical signs ; and the other, the development of the signs of pro-
gressive chronic disease in a manner almost sudden.

It appears certain, that in some cases, after a valvular lesion
has been established, the processes of organic change are either
wholly arrested, or advance with extreme slowness, so that,
should the condition of the heart’s cavities remain unaltered,
and the general health of the patient continue good, no symptoms
of heart disease will occur for many years, and the individual may
not only enjoy an apparently perfect state of health, but be able to
undergo violent and fatiguing exercises, and even indulge freely in
the use of stimulants. Such cases may go on for many years with-
out the occurrence of any symptom which awakens the attention
of the patient, or excites the apprehensions of the physician. Yet
all this time a valvular murmur has existed in the heart.

Now, it may often happen in such cases, that the patient,
having contracted some inflammatory affection of the lungs, con-
sults a physician who has had no knowledge of his previous history.
A stethoscopic examination is made, a loud murmur is detected,
and a twofold error is commonly committed : first, that the mur-
mur is supposed to indicate a recent and progressive disease, and
next, that the patient is suddenly, and for the first time in-
formed, that he has an organic disease of his heart. Physicians
who cannot help thinking aloud, or who, less excusably, are fond
of exhibiting their diagnostic tact to the patient, are but too
apt to commit these errors. The greatest evils now result, for
the chief safeguard of the patient is at once removed, and his at-
tention is painfully directed to the state of his heart, than which
there could be nothing better calculated to hasten its disease. But
this is not all: a long-existing change, which we might compare
to the cicatrix of a wound, is taken for a recent and progressive
disease. All the habits of the patient are altered by peremptory
mandates ; he is debarred the use of wine ; he is placed on a low
diet, and all action, exercise, and pleasurable excitement are for-
bidden. The discoverer of the disease, too, must now attempt to
cure it. Local and general depletion, mercury, digitalis, prussic
acid, blisters and issues, are summoned to lend their aid in at-
tempting an impossibility, and in doing that which ought not to

LATENCY OF VALVULAR DISEASE.

127

be done, namely, weakening the heart, and exhausting the general
nervous energy. Under such circumstances, and with the fear
of sudden death continually before the mind, the results are just
what might be expected : the action of the heart becomes enfeebled
and irregular ; its cavities dilate with or without hypertrophy ; and
dropsy and visceral congestion close the scene. I know of no case
more aptly illustrative of the evils of the nimia diligenlia medici.

The practical rule obviously should be, that when we acci-
dentally discover a valvular murmur in the heart of a patient,
whose previous health had been good, and who did not present
any of the symptoms of disease of the heart, we should be slow
indeed in communicating the fact to any one, least of all to the
patient himself. We must, without exciting his apprehensions,
seek to discover whether this murmur be the result of some long-
previous illness, or whether it be of recent origin : and if it appears
that the patient, during the past seven or ten years, had suffered
from rheumatic fever, with or without the symptoms of carditis,
we may with great probability conclude, that the disease origi-
nated on the occurrence of that affection. We must then examine
into the habits of the individual during the period in question, and
be very slow in advising any alteration in them, for common sense
must teach us, that any system of living which had preserved the
muscular portions of the heart from lesion, while the functions of
the organ remained in a state of health, and which had not
caused any advance in the valvular affection, should not be lightly
departed from. And, above all, we must avoid the unpardonable
error of treating a fixed and incurable organic change as a recent
and progressive disorganization.

With reference to the second of the points above indicated,
namely, the unexpected appearance of physical signs of chronic
disease within a short space of time, we shall here content our-
selves with the statement of the fact, reserving its full considera-
tion until after the diagnosis of valvular disease is examined.

128

CHAPTER II.

DISEASES OF THE VALVES OF THE HEART.

It would be foreign to the purpose of the present work to enter
into the long-agitated question of the causes of the heart’s sounds,
or to review the many conflicting opinions which have been put
forward on this subject. I have been long convinced that in each
series of observations on this point there was a source of error,
namely, that an attempt was made to explain the sounds and im-
pulse of the heart by reference to too limited a number of possi-
ble causes for their production. Thus, some have taught that the
sounds depended upon valvular tension ; some, on muscular con-
traction, and others, on the impulse produced by the current of
blood. But if we reflect on the number of physical circumstances
which, if’ not all concurring to produce the double stroke of the
heart, must take place in the short interval of time occupied by
each complete action of the organ, indicated by the arterial w ave,
we shall find that the number of operations or possible causes of
sound is very great. We have —

1. The auricular contractions.

2. The ventricular dilatations.

3. The ventricular contractions.

4. The auricular dilatations.

5. The opening of the auriculo-ventricular valves.

G. The opening of the arterial valves.

7. The closure of the auriculo-ventricular valves.

8. The closure of the arterial valves.

9. The entrance of blood into two auricles.

10. The entrance of blood into two ventricles.

11. The exit per saltum of the blood from two ventricles.

So that we have here not less than twenty-two operations, which,
however, if the heart is acting with regularity, may be reduced to
eleven, in consequence of the simultaneous action of the pulmo-
nary and systemic portions of the heart.

GENERAL CONSIDERATIONS.

129

It is certainly not proved that every one of these operations
produces sound. For example, we have no evidence that the
relaxation of a hollow muscle is attended with sound. Still,
even at the moment of this relaxation, a possible cause of sound
exists in the impulse of the blood against the walls of the cavity:
as occurs in aneurism from the entrance of the wave of blood into
the sac.

It may, however, be assumed that in the regularly acting heart
some of these operations have so much more to do with the pro-
duction of the sounds than others, that they should be considered
the principal, if not the only sources of the double sound : so that,
for practical purposes, we may admit that the first sound corres-
ponds to the ventricular systole, the second to its diastole. But
coincident with both these conditions there is a valvular tension:
in the ventricular systole the mitral and tricuspid valves are forci-
bly closed, while in the diastole the same condition is produced in
the semilunar and pulmonary valves. It is not yet determined how
much of the first sound depends upon muscular contraction, or how
much on valvular tension ; but this at least is certain, that, where
the muscular contractility of the heart is impaired, it is the first
sound that suffers most diminution. It is probable that in the pro-
duction of both sounds there is the double source of muscular
contraction and valvular tension ; but that the former has a greater
share than the latter in the production of the first sound ; while,
conversely, valvular tension has a greater share than muscular
contraction in the production of the second. The first of these
suppositions is, at all events, strongly confirmed by the fact of the
failure, or even complete cessation of the first sound, in certain
cases of typhus fever, attended with softening or weakening of the
ventricles.

Indeed the fact of the heart’s action continuing without a first
sound might lead to the opinion that valvular tension had no part
in the production of the sound. But it must be recollected that in
such cases the closing of the auriculo-ventricular valves cannot
take place wiih the same force as when the heart has full con-
tractile power, so that the valves are, as it were, shut silently.

We have thus, as the principal causes of the acoustic pheno-
mena of the heart’s action, three conditions, namely, the contrac-

vol. i. K

130

DISEASES OF THE VALVES OF THE HEART.

tion of its muscles, the closing of its valves, and the current or
wave of blood passing from one cavity into another. These are,
at all events, the sources of what may be termed the intrinsic
phenomena of the heart’s action, and have special reference to the
production of the first sound. The second sound, or that produced
by the arterial valves, on the other hand, maybe termed extrinsic,
and has relation to the motion of the blood after its departure from
the heart.

But it is obvious that the three first, or intrinsic phenomena
of the heart’s action, will be strong or weak, manifest or obscure,
in proportion to the strength or vivacity of the contractile force
of the heart, so that the character of these intrinsic cardiac actions
must depend on the vital force of the organ. Cceteris paribus, the
sound produced by the contractions of the cavities of the heart,
as well as that caused by the closing of the mitral and tricuspid
valves, and the sound, if any such there be, produced by the cur-
rent of blood will be strong or feeble in proportion to the vigour
of the heart.

With these views, we should expect to find the second sound
or the extrinsic phenomenon less influenced by the condition of
the heart than the first. We of course exclude from this con-
sideration cases of organic disease of the semilunar valves. Ex-
perience shows that alterations of the second sound are rare, com-
pared with those of the first, a circumstance which we should
expect, when we call to mind the low degree of organization and
simple structure of the arteries, as contrasted with that of the mus-
cular apparatus of the heart.

Compared with the arteries, the heart may be held to stand in
the relation, physiological and anatomical, of a red to a white-
blooded animal: and, pathologically, it is liable to avast number
of functional diseases ; to every form and result of inflammation,
except, perhaps, gangrene ; to hypertrophy, atrophy, and number-
less organic changes. The arteries, on the other hand, fulfil a less
active function ; their sympathies are but slightly marked, and their
diseases are more frequently those of deposition and transforma-
tion than of active inflammation. But they appear to be the go-
vernors of the extrinsic phenomena ; and hence these, or their re-
presentative, the second sound, arc rarely altered, as compared with

GENERAL CONSIDERATIONS. 131

the first class of signs, which embraces the impulse and the first
sound.

It will be seen by referring to the chapter on the condition of
the heart in Typhus Fever, that in by far the greater number of
cases of alteration or suspension of one of the sounds, that sound
was the first, and that in many instances so complete was its ob-
literation, that the double action of the heart appeared suspended,
nothing remaining but the second sound. I have suggested, that
in the rare cases in which the latter becomes feeble, there is a
diminution of the arterial force; but future observations must
determine whether this be owing to any alteration of the vital
contractility of the vessels, or of their elasticity alone.

It is, then, in the vital and anatomical conditions of the mus-
cular fibre that we find the key of cardiac pathology ; for, no
matter what the affection may be, its symptoms mainly depend
on the strength or weakness, the irritability or paralysis, the ana-
tomical health or disease of the cardiac muscles. It was long ago
observed by Laennec that valvular diseases had but little influence
on health when the muscular condition of the heart remained sound,
and every day’s experience confirms this observation. We may ex-
tend it to many other cardiac affections, at least so far as the pro-
duction of characteristic symptoms is concerned. Pericarditis with-
out irritability of the muscle is often so completely latent as only
to be discoverable by physical signs; and the same may, doubt-
less, be said of endocarditis ; while it must never be forgotten that
the important symptoms of these affections, as laid down in books,
have reference to lesions of either muscular action or structure.

The difficulties which the diagnosis of valvular disease pre-
sents to the student have been greatly increased by the conflict of
opinion as to the nature and causes of the sounds of the heart, and
by the various and opposite diagnostic rules laid down by writers,
according as they incline to this or that theory. Let us endeavour
to strip the subject of some of these difficulties, and to present it
as a guide sufficiently trustworthy for all practical purposes.

It too often happens, when the existence of a valvular disease
is determined, that great labour is expended in ascertaining the
exact seat and nature of the affection. Long and careful exami-
nations are made, to determine whether the disease exists at the

k 2

132

DISEASES OF THE VALVES OF THE HEART.

right or left side of the heart; whether it be a lesion of the mi-
tral, tricuspid, or the semilunar valves ; a contraction or dilata-
tion; an ossification; a permanent patency, or warty excrescence.
Now, though in some, we might say in many cases, these ques-
tions may be resolved with considerable accuracy, it is also true
that in a large number their determination is of comparatively
trifling importance ; and the two great practical points to be at-
tended to are, first, whether the murmurs really proceed from an
organic cause, and next, what is the vital and physical condition
of the muscular portions of the heart ; for it is upon these points
that prognosis and treatment must entirely depend. There is, in-
deed, no other organ whose affections more fully illustrate the
truth of this principle, that in dealing with the diseases of adja-
cent structures, diagnosis is easy where it is important, and of
little value where it is difficult or impossible.

Another source of the difficulties with which this subject is
surrounded is, that rules of diagnosis are in many cases founded
on the supposition of the isolation of disease ; but every practical
man knows that in chronic diseases of the heart isolation is the
exception, and complication the rule. Hence, one reason why
disease at the bed-side so rarely corresponds with its description
in books. Its combinations vary infinitely in their nature and
number; and we often find, particularly in cardiac disease, that
it is the more recent and least developed affection that produces
the most prominent physical signs. Hence, in many cases, while
we recognise a particular disease, we are unable to say whether
another and even more important affection co-exists.

We should by no means underrate the importance of differen-
tial diagnosis in valvular disease : but the number of cases m which
it is desirable to determine the exact seat and nature of the affec-
tion is comparatively small. Let us take the two most ordinary
forms of this disease, namely, the insufficiency, with contraction
on the one hand, and dilatation on the other, of the mitral and
aortic valves. Certain rules of treatment are supposed applicable
to each of these affections; but the truth is, that no constant state
of the heart’s muscles is attendant on them respectively, and it is
mainly on the vital and mechanical conditions of the cavities of
the heart that we can found any rule of treatment.

GENERAL CONSIDERATIONS.

133

Perhaps more value attaches to the question when considered
in relation to prognosis. In mitral-valve disease there is a greater
probability of sudden death than in the analogous affection of the
aorta; but if the cavities be yet unaltered, and the heart’s action
tranquil, there is in this disease a better chance of prolongation
of life than in that of the semilunar valves, for this latter affection
commonly leads to hypertrophy and dilatation of the left ven-
tricle. It will not be out of place to remark, that sudden death
in disease of the heart is by no means so frequent as is generally
supposed. In the great majority of cases, death occurs in no sudden
or extraordinary manner. It is principally in examples of solu-
tions of continuity, such as the rupture of an aneurism, the lacera-
tion of the ventricles, or the breaking of the chordae tendineae, that
this happens. We may add to this list a few cases of the fatty
degeneration of the heart in which, without rupture, death takes
place by a sudden syncope or a congestive apoplexy. But these
are the exceptions, and in the greater proportion sufficient notice
is given of the approach of death by long-continued symptoms of
dropsy, and of pulmonary and hepatic disease.

So general is the belief that sudden death is the inevitable
termination of disease of the heart, that the very suspicion of the
existence of such an affection leads to great and injurious mental
depression on the part of the patient, and corresponding anxiety
among his friends. It will therefore be right that the physician,
by appealing to the real facts of the case, should do his best to di-
minish those apprehensions.

Cases of valvular disease are of two kinds, those in which a
carditis has been manifestly the source of the affection, and those
in which we cannot trace the disease to any distinct attack of in-
flammation. In many of the latter the nature of the disease, as
Hasse and others have taught, is analogous to the atheromatous
and ossific affections of the arteries. And even in the first class,
after disorganization of the valve has taken place, and the disease
has become chronic, we have no reason for believing in the ex-
istence of even a chronic inflammation, and it is certain that we
gain nothing by treating such diseases as examples of chronic
carditis.

134

DISEASES OF THE VALVES OF THE HEART.

The various effects of organic disease on the function, struc-
ture, and form of the valves, is described in every work on pa-
thological anatomy. In a practical point of view, it would be
sufficient to recognise contraction or dilatation of the orifices, both
of which conditions are attended by a permanently open state.
This permanent patency is in some cases produced at an early pe-
riod of the disease, while in others the valves may be so roughened
by cartilaginous and ossific growths as to cause a murmur during
the exit of the blood, while they yet remain competent to close
the orifice. To this consideration we shall return, as it is one of
those which may be indicated as opposed to over-refinement in
diagnosis.

Valvular murmur is so much more frequently developed at the
left than at the right side of the heart, that it is still a question
whether we are in any case in a position to declare the existence
of disease of the tricuspid or the pulmonary valves. If the relative
position of the heart were always the same; if we had to deal only
with cases of valvular disease, uncomplicated with change in the
figure or volume of the heart; and lastly, if the rule were certain
that the loudest sounds were to be found at the exact situation of
the disease which produced them, it would be nearly as easy a
matter to diagnosticate valvular disease at the right as at the left
side of the heart. But when we know that the investigator can
seldom meet a case so circumstanced, and then reflect on the
greater frequency of diseases of the left side, it becomes plain that
the cautious physician ought not commit himself hastily in a
diagnosis of disease of the valves on the right side, much less de-
clare its exact nature.

For it appears certain that we must be guided in our treat-
ment of valvular disease less by the condition of the valves, than
by that of the muscular portions of the heart. The practical phy-
sician, having satisfied himself that a valvular disease exists, will
not devote too much time in ascertaining its exact nature ; but
he will examine into the vital and mechanical state of the heart’s
cavities. He will ascertain the amount of vigour of the heart,
whether its force is above or below the natural standaid; whether
it is liable to excitement from slight causes ; and whether irregula-
rity of action or the opposite is its ordinary state. He will endea\ our

SPECIAL DIAGNOSIS.

135

to determine the duration of’ the disease and its origin, and exa-
mine how far the brain, lungs, or liver, have suffered from the me-
chanical or vital effects of disease of the heart. Thus he will ob-
tain some rule of treatment, and as the two most common diseases
of the orifices, viz., permanent patency of the aortic and mitral
valves, when occurring in an isolated form, are not difficult to
distinguish, he will, so far as treatment and prognosis are concerned,
be able to give to the patient all the advantages which the present
state of medicine can afford.

In order to present this matter plainly before the reader, strip-
ping the question of whatever is doubtful or unascertained, we
shall suppose a certain number of cases or examples in which
such a diagnosis as appears justifiable and of practical utility may
be made.

UNCOMPLICATED DISEASE OF THE MITEAL VALVES.

Permanent murmur, with the first sound loudest towards the apex
and to the left side, and not heard in the artery ; second sound na-
tural.— In this combination we have the common indications of
organic disease of the mitral valves. The character of the murmur
varies in different cases, and the sign may be distinguished, in
most instances at least, from that produced by disease of the semi-
lunar valves, in its being louder towards the apex than the base of
the heart. It may be a smooth bellows sound, or present a grating
character, with or without musical tone, and fremitus may or may
not be present.

Now if the heart’s action be regular, if the pulse have its na-
tural fulness and character, if the impulse of the heart be not ex-
cited, we may consider such a case as an example of uncompli-
cated mitral-valve disease. If, on the other hand, the action of
the heart be tumultuous and irregular, if the pulse be feeble and
unequal, and the lungs show symptoms of congestion, we may
suspect that the orifice is contracted and the heart otherwise
diseased.

136

DISEASES OF THE VALVES OF THE HEART.

DISEASE OF THE AORTIC VALVES, WITH PERMANENT PATENCY.

The first sound unattended with murmur; the second replaced
by a murmur which can be perceived to be double ; this murmur
is more or less audible along the course of the aorta , and, as regards
the heart , is generally louder at the base than towards the apex. —
The phenomena now described belong to disease of the aortic
opening, and indicate that regurgitation into the ventricle takes
place, owing to the defective condition of the valves. Such cases
may be divided into two classes : those in which the disease is in
an early stage, and those much more chronic, when the usual
consequences of an hypertrophied and dilated ventricle have su-
pervened. In the first case there may be no evidence of enlarge-
ment of the heart, and the characteristic visible bounding pulsa-
tions of the arteries may not be developed, or only seen in the
neck. But in the more advanced periods we have, in addition to
the loud double murmur at the aortic orifice propagated into the
aorta and large arteries, the remarkable symptom of the visible
pulsations of not only the great trunks, but of many of the smaller
arteries which approach the surface. The radial pulse becomes
quite characteristic. This is the jerking pulse, “ the pulse of un-
filled arteries” of Dr. Hope11, and we have no difficulty in recog-
nising an enlargement of the left ventricle, if not of the entire
heart. We owe the diagnosis of this disease to Dr. Corrigan.

DISEASE OF THE AORTIC VALVES, WITHOUT PERMANENT PATENCY.

The action of the heart slow, feeble, but generally regular, or only
occasionally intermitting ; a murmur with the first sound; the second
sound healthy, yet a single murmur existing in the aorta and its large

» Dr. Hope observes, that this character of pulse is produced by aortic regurgitation,
in other cases as well as those, where the reflux is into the left ventricle. He instances
cases of communication with the pulmonary artery, or the mouth of the left ventricle. I
have noticed this symptom in a case of true aneurism of the ascending aorta, in which
the valves were competent to close the orifice. The name of collapsing pulse would be
more appropriate, as the sensation given to the finger is that of a sudden disappearance
of the arterial wave, which, as Dr. Corrigan has shown, is produced by the retrograde
motion of a portion of the blood. See his original Memoir, Edinburgh Medical and
Surgical Journal, April, 1832.

SPECIAL DIAGNOSIS.

137

branches. — This case, which is not unfrequent, would seem to jus-
tify the following diagnosis: Disease of the aortic opening causing
murmur during the exit of the blood; the valves, however, being
able so to close as to prevent regurgitation. To this may be safely
added, that the heart is weak, and that in all probability this
weakness proceeds from fatty degeneration. Indeed, when the
pulse falls below 50 we may make the double diagnosis with
considerable certainty.

Here the aortic valves are diseased, but not permanently pa-
tent. Hence, there is no regurgitant murmur, and we have the
second sound unaffected, because the valves close more or less
perfectly. The aortic murmur is propagated from the origin of
the vessel, where it arises during the exit of the blood. This
curious combination I have already described in a memoir on
slow pulsea, and it is more than probable, though I cannot confirm
this by recorded observations, that the murmur in such cases will
be louder at the base than at the middle or the apex of the heart.
We have thus produced from organic causes that group of acoustic
signs which is often observed in ansemia, namely, the triple com-
bination of a murmur with the first sound, a clear second sound, and
yet a murmur in the aorta. When, however, all the circumstances
of the case are considered, and especially when the co-existing
signs and symptoms of a degenerated left ventricle are taken into
consideration, there will be but little difficulty in coming to a
correct conclusion as to the nature of the disease.

Such are the cases in which special diagnosis of valvular dis-
ease may be safely made. It is laid down by Dr. Hope, that the
regurgitant diseases of the pulmonary and tricuspid valves may
be made by applying the necessary inversions. Thus, according
to him, the signs of diseases of the tricuspid valves are the same
as those of the mitral, except that the murmurs are loudest on
01 near the sternum, at the same level as in the case of the mi-
tral disease, namely, about or a little above the apex of the heart;
and except, also, that the pulse is little affected with irregularity.
But anatomical considerations should make us cautious in admit-
ting these statements.

Dublin Quarterly Journal of Medical Science, vol. xi. 1846.

138

DISEASES OF THE VALVES OF THE HEART.

Again, lie observes that, when there is regurgitation through
the valves of the pulmonary artery, a murmur accompanies the
second sound ; its nature and diagnosis are the same (the necessary
inversions being made) as in the case of aortic regurgitation, ex-
cept that the pulse is not jerking. A purring tremor has been
found to attend dilatation of the pulmonary arterya.

It has been already observed, that the practitioner should use
great caution in giving a diagnosis, not only of the nature, but of
the very existence of valvular disease at the right side of the
heart ; and Dr. Hope himself has dwelt on the necessity for the
exercise of this caution, and pointed out that the signs he has
specified must be perfectly well marked to justify the opinion.
But although, in the last edition of his work, tills excellent ob-
server has not dwelt so strongly on the attainable certainty of special
diagnosis in valvular disease, he still, I think, underrates the
sources of difficulty that must accompany all attempts to discrimi-
nate the valvular diseases of the right side of the heart.

DILATATION AND FEEBLENESS OF THE HEART, WITH OR WITHOUT

VALVULAR DISEASE.

The heart's action permanently irregular , ivith an extended , but
not a strong impulse; the sounds so rapid and unequal that their
analysis is difficult, rendering it often impossible to distinguish the first
from the second sound; murmur generally absent; the pulse rapid,
feeble, unequal, irregular ; no aortic murmur; signs of pulmonary and
hepatic congestion. — This is one of the cases of heart affection to
which the practitioner’s attention will be most commonly directed ;
and though valvular disease is by no means a necessary attendant
upon it, it is introduced here because it is considered to be
almost always accompanied by some form of that affection.
Valvular murmur is generally absent, or it may exist for a time,
and then disappear; and it is certain that no constant morbid
state of the valves attends the disease. The orifices may be di-
lated or contracted. It occurs in gouty and debilitated habits,
and is almost always attended with chronic bronchitis and en-
largement of the liver.

* See Hope.

SPECIAL DIAGNOSIS.

139

The diagnosis in this case is to be, that the heart is generally
thinned, dilated, and weakened, the probabilities being strongly
against the existence of any important disease of the valves. To
the consideration of this disease we shall return.

EXTREME OSSIFIC DISEASE OF THE AORTIC ORIFICE.

Strong action of the left ventricle; extremely loud and musical
murmur at the aortic orifice, transmitted through the whole extent
of the arterial tree; the heart’s action generally regular. — I have
witnessed two or three cases of this combination. The phe-
nomena arise from extensive ossific disease of the aortic open-
ing, which is rendered not only rigid, but singularly irregular,
Irom the deposit of great quantities of earthy matter in the form
of intersecting and irregular plates, stretching downwards into the
ventricle, as well as into the aorta, for an inch above the sinuses.
In one of these cases the appearance of the opening might be
aptly compared to that of the mouth of a shark in miniature ; all
traces of the valves had disappeared.

In these cases every superficial artery emitted a most distinct
musical tone at each pulsation : the radial artery at the wrist, the
palmar arteries, the ramifications of the temporal arteries, the an-
terior tibial, and the branches on the dorsum of the foot, all exhibi-
ted the same phenomenon. In two cases the sounds were distinctly
audible to the patients, who were conscious of their existence at
almost every point of the body. With one patient the perception
of these sounds was the principal cause of his suffering, for his
general health long continued excellent, and the heart’s action
was but little excited. This gentleman once observed to me, that
his entire body was one humming-top. The loudness of the tone
varied with the force of the heart. When I first saw him the
sounds were audible at the distance of at least three feet ; but
when the force of the heart had been reduced by local treatment,
the use of sedatives, and by removing all causes of bodily and
mental excitement, the loudness of the sound at the aortic orifice
was so much reduced as to render it inaudible, unless by applying
the ear. Even under these circumstances the musical sound of
the small arteries still continued, though not to such a degree as to
cause annoyance to the patient. Dissection in this case showed

140

DISEASES OF THE VALVES OF THE HEART.

but little disease in the aorta from about two inches above the
orifice ; the descending aorta and the arch were healthy ; the left
ventricle was hypertrophied and dilated ; the general arterial sys-
tem exhibited no disease.

Under such circumstances we may safely make the diagnosis
of extensive and irregular ossification of the aortic orifice, with
contraction, if the pulse be small and hard, and without contrac-
tion, if its ordinary volume be preserved.

To these cases, presenting physical signs sufficiently constant
and well-marked to justify such a diagnosis of the condition of the
valves as will be safe or practically useful, we may add the case of
varicose aneurism, of which a description will be found in the
section devoted to that subject.

But the practitioner must be prepared to meet with many
cases which he will be unable to refer satisfactorily to any of these
forms ; for the complications of heart disease are so numerous and
varied that, as we have said before, it becomes impossible to de-
termine the exact nature of every case that may come before us.
Fortunately it is unnecessary to do so, for if we can be certain
that organic disease really exists, the treatment, as has been be-
fore remarked, will depend less on the nature of the valvular
affection than on the vital and anatomical state of the heart itself.

Among the causes which concur to produce such varied phe-
nomena in heart disease, the following may be enumerated :

1. The existence of valvular disease in more than one situation.

2. The changes incident to the advance of disease.

3. Alterations in the muscular structure of the heart.

4. Variation in the action of the heart.

5. Intercurrent attacks of endocarditis or of pericarditis.

6. Variations in the condition of the blood itself, causing the
appearance and disappearance of amende, in addition to the or-
ganic murmurs.

To this catalogue other causes might be added ; but the prac-
tical physician, knowing these things, will not feel that the diffi-
culties of the subject reflect disgrace upon his art, when he con-
siders that the great end of medicine is the proper treatment of the
patient, rather than the exhibition of unnecessary refinement in
diagnosis.

ABSENCE OF VALVULAR MURMUR.

141

Tn connexion with this subject it is to be observed that many
fall into the error of supposing that the loudness of the valvular
murmur is proportioned to the extent of disease ; and again, that
murmur is so constantly associated with valvular disease, as that
the absence of the former implies a freedom from the latter. But we
know that in the arteries, at least, a very loud murmur may occur
without any organic cause : and the existence of antemic murmurs
in the heart has been long recognised. We cannot then declare,
that because a murmur is very distinct, the disease must be
very considerable; nor can we, on the other hand, pronounce
absolutely upon the healthy state of the valves merely because we
can hear no murmur. This rule of course applies specially to
those cases in which the symptoms, signs, and history lead us to
suspect organic disease of some kind. We may lay it down as
generally true that valvular murmur, once established as a conse-
quence of valvular disease, continues, though showing occasional
modifications, up to the period of death. But this is not always the
case, and it is certain that the decrease of murmur may coincide
with the increase of disease ; and further, that in a case where
at one time valvular disease was distinctly indicated by its proper
murmur, this latter may wholly cease long before death, and when
the organic affection has reached its greatest amount. This im-
portant fact is exemplified by the following case :

Case XYI. — Ossification and Contraction of the Mitral Valves;
complete disappearance of murmur before death.

A man past middle age was admitted into the Meath Hospital,
labouring under the usual symptoms of disease of the heart, in
connexion with chronic bronchitis and dilatation of the air-cells.
He was affected with cough, dyspnoea, occasional orthopnoea,
lividity of the countenance, and anasarca of the lower extremi-
ties. The action of the heart was much excited and irregular,
with a corresponding pulse. A loud and permanent bellows
murmur was heard in the region of the mitral valve; the second
sound was healthy. Under treatment directed to relieve the lung
the urgent symptoms subsided, and he left the hospital, to all
appearance convalescent, but still exhibiting the valvular murmur.
Some months subsequently another attack supervened, and we

142

DISEASES OF THE VALVES OF THE HEART.

liad a second opportunity of studying the case ; and again he left
the hospital, the condition of the heart remaining unchanged. We
now lost sight of him for almost two years, when he again was ad-
mitted, labouring under his old symptoms, but in a very aggra-
vated form. His strength had greatly given way, and the condi-
tion of the lung was such that death seemed imminent. The ac-
tion of the heart was violent and distressing in the highest degree,
but all valvular murmur had ceased, and never re-appeared. He
was for a time relieved by treatment, but ultimately sunk under
dyspnoea, after a protracted struggle. On dissection, the lung
was found to exhibit the most extreme degree of emphysema,
with sub-pleural vesicles and dilated tubes. The heart was large,
red, and firm ; both ventricles hypertrophied. The mitral opening
was completely surrounded by a ring of bone. It was contracted,
and exhibited no trace whatever of valves or tendinous chords.
Viewed from the auricular side it presented a funnel-shaped
opening, ending in the crescent-like slit described by Dr. Adams,
while on the ventricular side it showed nothing but a glistening,
white, bony ring, as smooth as polished ivory. Here, then, there
were narrowing and induration of the orifice, and doubtless, also,
free regurgitation; but yet the murmur which had existed in
the earlier stages of the disease had totally disappeared. The
subsidence, too, of this murmur was not to be explained by the
weakness of the heart, for the left ventricle continued in vigorous
action up to the time of his last agony, and its muscular structure
was red and firm. Had this patient been seen by us only at the
time of his last admission no one would have thought of making
a diagnosis pf valvular disease. But the case is strongly illustrative
of the principle, that where other circumstances indicate disease
of the heart, the mere absence of murmur should not necessarily
make us declare that the valves are healthy*1.

In the case now given we observed great valvular disease

a The existence of the double sound of the heart in the latter period of this case, after
the destruction of the valve and the cessation of the mitral murmur, is interesting, as
bearing on the cause of the first sound, which here could only have proceeded from the ven-
tricular systole, and the closing of the tricuspid valve. Dr. Hope attributes the fiist
sound to the tension of the valve, and also to muscular contraction, hut thinks that the
latter has the smallest share in its production.

ABSENCE OF MURMUR.

143

without murmur; yet at an early period of the affection well-
marked murmur existed. In the next case we never observed
murmur, and yet extreme valvular obstruction was found. It
is probable that, had this patient been seen at an earlier period of
the disease, the murmur would have been observed.

Case XVII. — Extreme Contraction of the Mitral Valve; Absence

of Murmur.

A woman of middle age was admitted into my wards, la-
bouring under aggravated symptoms of heart disease. The
impulse was jerking and sudden, and the action of the heart
intermitting and unequal. She suffered from cardiac anguish,
want of sleep, and constant palpitation. The sound on percus-
sion over the heart was clear, and both the first and second sounds
were sharp and distinct, and totally without murmur. This ob-
servation I confirmed by many examinations, and under different
states of the heart’s action. On dissection the heart was found but
little enlarged. The left ventricle was thickened and extremely
firm, and the mitral valve so contracted that the orifice, which
was irregular, could hardly admit an ordinary-sized quill.

It is now many years since the first of these cases occurred in
the Meath Hospital, since which I have always taught in my
clinical lectures that, with the advance of valvular disease, there
might be a progressive diminution, and ultimately a complete
cessation of murmur. It is to Mr. O’Ferrall, however, that we
owe the publication of an important series of observations on this
subject, in which he gives several well-observed cases illustrative
of the disappearance of murmur in progressive valvular disease®.
He believes, indeed, that with the advance of disease of the valve,
the valve may be so altered as to prevent regurgitation, and that
hence the regurgitating murmur disappears. On this point I shall
not now offer any opinion, but refer the reader to Mr. O’Ferrall’s
memoir, which is one of great value. Explain it as we may, the
great practical observation remains, that in certain cases of
chronic valvular disease we may observe a diminution and ulti-

a Clinical Researches in St. Vincent’s Hospital, by J. M. O’Ferrall, M. R. I. A., &c.
Dublin Journal of Medical Science, First Series, vol. xxiii. 18-13.

144

DISEASES OF THE VALVES OF THE HEART.

mately a disappearance of the murmur, indicative not of any cure
or diminution of the disease, but really of its increase. And, as
has been well shewn by Mr. O’Ferrall, such a diagnosis is not
difficult when, coincident with or subsequent to the disappearance
of the murmur, we find the continuance or increase of the or-
dinary symptoms of disease of the heart.

So much has been written on the differential diagnosis of the
valvular diseases that, to many at least, the preceding sketch of
the subject will appear meagre and insufficient. But the great
principle which is to be insisted on is, that the number of the
special combinations of signs and symptoms which warrants a
special diagnosis is but small. And, again, that in most examples
of the second category, namely, those in which the differential
diagnosis is doubtful or impossible, there will generally be no
difficulty in determining not only that the disease is organic, but
also what is the vital state of the heart, and the mechanical con-
ditions of its cavities and its walls. We may, as has been shown,
determine with sufficient accuracy three forms and seats of val-
vular disease, namely,

1. Disease of the mitral valve.

2. Disease of the aortic valve with permanent patency.

3. Disease of the aortic orifice without permanent patency.

But when it is asked — can we say whether the disease of the

mitral valve is a narrowing or a dilatation, an ossification or a
merely cartilaginous thickening? — we must answer in the nega-
tive. If we are asked — is the disease confined to a single valve ? —
we can, in many cases, give but a doubtful answer. If the ques-
tion is raised —can we always determine whether the valvular
disease affects the pulmonary or systemic portions of the heart?
the answer ought to be, that we have little but probability to
guide us, for in any given case of valvular disease the chances
that it exists at, or at all events predominates in, the left side, are
very great. To distinguish, by referring to the points of greatest
intensity of murmur, between the diseases of the valves on the
right and left sides of the heart, cannot be safely done. This doc-
trine I have held and taught for many years, and as clinical ob-
servation advances we see its truth impressing itself on the minds

OBSERVATIONS OF FORGET.

145

of independent observers. On this subject the following remarks
of M. Forget are of great value:

“ Is it true, as we hear it daily repeated, that the two hearts
are situated, the one at the left and the other at the right side ?
So far as the cavities are concerned such an arrangement exists
but partially. It has been well observed by Bouillaud, Piorry,
and others, that the right ventricle covers a portion of the left
ventricle, before which it is thrown by means of the angular por-
tion, whose summit corresponds to the orifice of the pulmonary
artery.

“ As to the auricles, the want of parallelism is still more evi-
dent. It is easy to perceive, in fact, that the left is thrown back-
wards and completely hidden by the common mass of the aorta
and pulmonary artery ; while the right, situated much more an-
teriorly, is projected towards the left; so that the right auricle
alone is in contact with the sternum, to say nothing of the inter-
position of the anterior borders of the lungs.

“ If we consider the relative position of the valvular orifices
of the heart, we may strictly hold that the auriculo-ventricular
openings occupy a left and right position, although the tricuspid
orifice, like the cavity whose base it occupies, intrudes on the
initial to the extent of about a centimetre. Finally, the external
angles of the auriculo-ventricular orifices stretch to the right and
the left, but, in the case of the arterial openings, it is the reverse
which occurs, for these orifices are exactly placed one above the
other.

1 hese anatomical facts are manifest to all. How has it hap-
pened that they have been so long unrecognised, and that it is
still imagined by observers that the cavities of the heart are re-
gularly placed to the right and to the left, and that the right and
left orifices are perfectly isolated?

But this is not all, for the four orifices of the heart are so
crossed, superimposed, and grouped, that their isolation is nearly
impossible. I lie auriculo-ventricular orifices are only separated
from the arterial openings by the thickness of the fibrous band
suirounding the base of the ventricles, so that within a. surface
which could be covered with a five-franc piece, we find contained

VOL. i.

146 DISEASES OF THE VALVES OF THE HEART.

and superimposed the two arterial openings, and the greater por-
tion of the two auriculo-ventricular orifices”*.

LATENCY OF CHRONIC VALVULAR DISEASE.

The doctrine that disease of the valves, when it is uncompli-
cated with any functional or organic lesion of the muscles of the
heart, is often so latent as to he undiscoverable without physical
examination, is one of the great truths for which we are indebted
to the genius of Laennec. And it is not yet sufficiently insisted
on, that valvular disease, even to an extreme degree, may affect
the heart without there being anything in the previous history or
existing symptoms which could lead us to suspect the existence
of such a lesion.

A slow and, as it were, silent disorganizing process may be de-
veloped in one or more of the valves of the heart, without pain,
without irregularity of action, without any circumstance which
could awaken the attention of either the patient or physician;
and thus years may pass by, the patient fulfilling without incon-
venience all the duties of an anxious, active, and energetic life.

But, with the want of symptoms, there is, doubtless, for
a period which is undefined, absence of physical signs as well,
and though the disease is manifestly progressive, no murmur is
established until the mechanical change has reached that point
which is competent to produce acoustic signs attendant on the
flow of blood through the altered orifice. Thus it often happens
that we may, with great care, examine the heart and find no evi-
dence of disease, yet in a short time, it may be in a few days,
manifest physical signs are developed which indicate not a recent
and acute disease, but an extremely slow and long existing affec-
tion, yet one which had not, until the period of the second exa-
mination, arrived at the point when it was at last attended with
acoustic phenomena.

In the chapter on carditis I have dwelt on the error which is
so commonly fallen into of considering a murmur which had ex-
isted for a long period, but was then for the first time observed,

» Precis des Maladies du Coeur, &c., par C. Forget. P. 7.

LATENCY OF VALVULAR DISEASE.

147

as evidence of a recent and inflammatory affection. The same
error is too often witnessed in the case now under consideration,
and, as might be expected, the same disastrous consequences are
found to follow.

The effects of injudiciously communicating to the patient that
his heart is organically diseased, in conjunction with those of an
ignorant and destructive medication, produce that very condition
the absence of which has been the patient’s chief safety. The
heart becomes irritable, irregular, perhaps excited, and it is then
no wonder that the symptoms of disease are superadded to the
signs.

The recent development of the signs of a chronic, long pre-
existing disease is a circumstance which should be known to all
who are concerned in the medical examinations for life insurance.
Thus, it may happen, a life is passed as insurable after a careful
examination. The insurance is effected, and yet in a short time
the individual exhibits all those signs of morbus cordis which
are supposed to indicate chronic disease. He may die of this
disease within a few months after the completion of the insurance,
and the payment of the sum insured be then contested on the
ground that the disease was overlooked. I have known all the
signs and symptoms of permanent patency of the aortic valves to
occur within a few months after the effectuation of a large insu-
i ance, and yet at the period of the medical examination, which was
made by one of the best observers in this or any other country,
no sign of disease of the heart existed. In the same way I
have known the signs of chronic mitral disease become most
strongly developed in the course of a few days. These facts are
of practical importance, for in the case of a judicial trial, on the
ground of the incompetency or neglect of the medical examiner,
many professional witnesses would incline to the opinion that the
affection had been overlooked rather than that it had become de-
v eloped in so short a time after the examination. They would
be influenced by the opinion that the development of disease and
of its symptoms and signs are concurrent, a doctrine which we
have seen to be untenable in acute, and, of course, far more so
in chronic disease.

It is not impossible that in some cases physical signs may be

l 2

148

DISEASES OF THE VALVES OF THE HEART.

developed at so early a period of chronic valvular disease that
we may consider these signs as of little less duration than the or-
ganic change, but such a case appears to be an exceptional one.
And in most instances a long process of progressive disorganiza-
tion has in all probability been going on before the mechanical
conditions of the parts are so altered as to cause distinct physical
signs®.

We have already spoken of the error committed in taking
chronic disease of the valves for an acute affection. This mis-
take is unhappily but too common, and in connexion with it two
errors are generally made ; first, in supposing the disease to be
of recent origin ; and next in believing it to be necessarily pro-
gressive. It would appear, however, that some valvular diseases,
at all events, are either not progressive, or that they advance with
such extreme slowness as to constitute a class of cases very different
from the more common examples of these affections. Some of the
evils which result from this error have been already pointed out,
but the following case will illustrate the importance of these ob-
servations :

It is now many years since I was consulted by a gentleman
under the following circumstances. The patient, after having
enjoyed excellent health for several years, was attacked by an
influenza, then epidemic, and in consequence of considerable
bronchial irritation, consulted a physician. He did not complain
of any symptoms referrible to the heart ; but his medical at-
tendant, while exploring the chest with a view of determining
the amount of bronchitis, discovered a bellows-munnur masking
the first sound of the heart at the left side. The patient was
then informed that he laboured under disease of the valves of his
heart, and the diagnosis was confirmed in consultation with some
eminent members of the faculty. All his habits were imme-
diately changed; he was accustomed to active exercise on horse-
back and on foot, and was in the habit of drinking wine freely,

* To use the apt illustration of a friend of mine, an American physician, who has been
studying in Dublin during the present year, the case may be compared to that of the
building of a tower at one side of a hill, the greater part of which must be completed be-
fore those on the other side are able to perceive its elevation above the horizon.

LATENCY OF VALVULAR DISEASE.

149

but all exercise was forbidden except slow walking on a level
surface, while he was put on an extremely spare diet, and com-
plete abstinence from fermented liquors was enjoined. This
total change in his habits, coupled with the usual results of un-
necessary medical treatment, and the apprehension of sudden
death so unexpectedly brought before the mind of an ardent
young man engaged in an active profession, produced, as might
have been anticipated, an extremely depressed condition of mind
and body. It was under these circumstances that I first saw him.
He was of a full habit; the pulse perfectly regular and of fail-
strength ; and the heart’s action tranquil. He assured me that
he had never felt any palpitation or uneasiness about the heart
until after the period when this murmur had been discovered; in
other words, until after the time at which he had been forbidden
to use stimulants or active exertion. I found a distinct, but not
rough murmur with the first sound of the heart, confined to the
region of the mitral valve ; the lungs were healthy, and it ap-
peared that he never had an attack of pulmonary congestion or
irritation except that one for which he consulted the physician.
Taking into account the previous good health and habits of this
patient, and the fact that no symptoms of pericarditis or endocar-
ditis had been observed in connexion with the attack of influenza,
and also that his general health, and even the condition of his
heart, appeared to have suffered by the change in his mode of
living, — I suspected that this murmur was indicative of some very
old, passive, and stationary valvular disease, and this suspicion
was converted almost into a certainty by the patient informing
me that seven or eight years previously he had suffered from a
severe attack of rheumatic gout, which affected many of the joints.
There could then be hardly a doubt that the murmur was esta-
blished at that time, but that the diseased action had not been
progressive ; the valves had been mechanically altered, but not to
such a degree as to interfere materially with their functions. So
that we had in this case to deal with the cicatrix of a wound, as it
were, rather than with the wound itself. I explained these views
to the patient, and endeavoured to re-assure him as much as pos-
sible. He was advised not to give up his profession, and was al-
lowed to use stimulants in moderation. Smoking was forbidden ;

150

DISEASES OF THE VALVES OF THE HEART.

and I directed the patient to return to me within a year. He did
so ; I found him much improved in appearance and spirits, while
the physical signs of the heart remained quite unchanged. I saw
this gentleman once annually for several years. On the last oc-
casion but one he had just returned from a shooting excursion in
the highlands of Scotland, which had occupied nearly a month.
During this time he was on foot, walking over mountains for
eight hours a day, carrying a heavy gun and shot-pouch, and using
a liberal allowance of diffusible stimuli, yet he never experienced
any difficulty in respiration, and when I saw him he was in the
highe'st state of health and spirits. It is now more than a year
since I have seen this gentleman; he was then in perfect health,
although the murmur continued unchanged.

That this individual has had a continued mitral murmur for
upwards of twelve years, there cannot be any reasonable doubt,
and the case is strongly illustrative of this principle in practice,
— that we are not to confound the effects of a disease witli the
disease itself; and again, that we are not rashly to change the
habits of living, as to exercise and the use of stimulants, in a
patient who has been the subject of a chronic local disease, if we
find that under the regimen in question, local disease has not
been progressive, and that the general health has remained un-
impaired.

Other cases might be adduced of the long continuance of
murmur in the heart without any special symptom of disease, and
we may even see men with a loud rasping murmur continuing
for years, who are yet able to take violent exercise. I knew a
gentleman who was advanced in life, and who had to my know-
ledge a loud and rough mitral murmur for four years, yet during
each season he rarely missed a day’s hunting, and was a bold and
fearless rider.

Another case, in which the practitioner will do well to observe
extreme caution in diagnosis and prognosis, is that of the com-
bination of organic and anaemic murmurs. This combination
is not unfrequent, especially in young females, and it is often
difficult to say whether the organic or the functional disease has
had the initiative. Under these circumstances we have generally,
with the symptoms of anaemia, the physical sign of a mitral mur-

LATENCY OF VALVULAR DISEASE.

151

raur unattended by evidence of hypertrophy of the heart. Who
can say at the first, or even after many subsequent examinations,
what is the actual condition of the heart in such a case ? He would
be rash indeed who would declare that there is no organic affec-
tion, especially when he reflects that the combination of an organic
disease of the heart, sufficient to cause murmur, and of that state
of the blood which produces the murmurs of anaemia, may not only
arise, but is in all probability one of frequent occurrence. Of these
observations the following case is an illustration.

Case XVIII. — A young girl, aged 18, presenting all the cha-
racteristics of anaemia and chlorosis, was under my care in the
Meath Hospital in the year 1842. She presented the signs of
organic disease of the mitral valves, but on taking her age and
general condition into consideration, I suspended my diagnosis as
to the actual state of the heart, and contented myself with endea-
vouring to improve the general condition of the patient. She sub-
sequently came under the care of Dr. Bigger. She died in De-
cember, 1842 (having been altogether more than two years ill),
with symptoms of congestion of the lung and anasarca. On dis-
section the left auriculo-ventricular opening was found to be
funnel-shaped, and so contracted as scarcely to admit the passage
of a quill. The aorta and its valves were in a healthy state ; the
left auricle was distended and its parietes thickened11.

I adduce this case as an example of one of those in which the
practical physician should abstain from a positive diagnosis as to
the condition of the heart. When I saw the patient the physical
signs were unquestionably those of organic disease of the mitral
valves, but her age, anaemic condition, and the periodicity of hex-
attacks, made me hesitate to declare what proportion of the phe-
nomena wa3 to be attributed to organic or to functional lesion.

In a communication which I made to the Pathological Society
I mentioned the case of a lady, aged 20, who presented all the
symptoms of the anaemic condition. She had violent palpitations
after exercise, swelling of the feet, some lividity of the lips, and a
loud musical murmur with the first sound of the heart. The se-
cond sound was healthy, but the loud musical murmur was audible

See Transactions of the Pathological Society, Dublin, Jan. 1843.

152

DISEASES OF THE VALVES OF THE HEART.

in the aorta and its primary branches. There was no evidence of
enlargement of the heart, and the lady was not hysterical. She
was repeatedly seen by Dr. Chambers, Sir Philip Crampton, and
myself, and the question as to the presence or absence of organic
disease was never determined. She was, however, treated by
clialybeates, tonics, and other measures calculated to improve the
anaemic condition ; and with this remarkable result, that all symp-
toms of chlorosis vanished, that the murmur left the arteries, that
the symptoms of heart affection disappeared, so that she was able
to ride, walk, and dance, with pleasure; but the mitral murmur
never subsided, although it lost much of its musical character.
She continued for three years to all appearance in perfect health,
when, while in the act of leaving her father’s door, on a visit of
charity, she suddenly dropped dead.

This was manifestly a case of the combination of organic and
antemic murmurs, yet one in which a positive diagnosis was at
first simply impossible. In speaking of anaemic murmurs gene-
rally, I shall return to this case, here only remarking that the dif-
ficulty which attended the diagnosis, at least in the earlier periods,
did not interfere in any way with the proper, and as far as was
possible, successful treatment of the patient. In this case, as the
nature of the disease was doubtful, we held it right to give the
patient the benefit of that doubt, and accordingly attention was
directed more to the general than to the local state. We could
not say whether the mitral murmur was wholly functional or
partly organic, but we could recognise the anaemic condition from
the general history of the patient, the scanty uterine action, and
the arterial murmur while the second sound remained clear. To
this condition, then, our treatment was directed ; and it must be
admitted by every one familiar with cardiac disease that the life
of this admirable lady was prolonged by a treatment in which the
organic disease was really neglected, and which, at least in the
opinion of many, would have tended to its exasperation, foi the
remedies by which she regained her health were, iron, bark, wine,
and active exercise, in conjunction with a full participation in all
the enjoyments accessible to persons in her rank of life.

The preceding observations naturally lead us to inquire into the
absence of symptoms as well as signs of confirmed affections of the

LATENCY OF VALVULAR DISEASE.

153

heart. It will be found that this is not so unfrequent as might be
supposed. A slow organic change of one or more orifices of the
heart may go on without exciting any symptom which leads to
the suspicion of disease ; and the heart, by some power of adapta-
tion, seems to adjust its action, so as to carry on the function of
circulation without manifest disturbance. But on the occurrence
of any general disturbance of the system, the signs and symptoms
of a diseased heart are suddenly developed.

I exhibited in 1840, to the Pathological Society, the heart of
a gentleman of middle age, which illustrated the above posi-
tions. The patient was a man of exceedingly active habits, who
had up to his fatal illness enjoyed uninterrupted health. A few
days before his death he was attacked with rigors, followed by
symptoms of fever, attended with bronchial irritation. In this
state he remained for two days, when he was seen by his physi-
cian, who found him labouring under fever, bronchial inflamma-
tion, and extraordinary excitement of the heart. The pulsations
were exceedingly violent and tumultuous, and were diffused over
a large portion of the chest. A bellows-murmur with the first
sound attended these violent pulsations. For three or four days
he went on tolerably well, when he expired suddenly. On dis-
section the brain was found healthy, but the heart exhibited some
singular appearances. The left ventricle was distended to the last
degree with fluid blood, and the aortic opening exhibited the
most extreme amount of obstruction from ossific deposits that I
have ever seen or read of. At first, indeed, it seemed as if there
was no opening; but when examined on the ventricular side a
very small slit was discoverable of about four lines in length and
one in breadth, through which it was just possible to pass a fine
probe.

Now this patient had never exhibited any symptom of heart
affection up to the time of Ins fatal attack, nor had his medical
attendant the slightest suspicion that chronic disease of the heart
existed. Had this gentleman been presented for a life insurance,
it is probable that, so far as his history and symptoms would go,
he would have been passed as an excellent life. We cannot say
that a physical examination of the heart would not have revealed
this extraordinary disease, but it is quite possible that it would

154

DISEASES OF THE VALVES OF THE HEART.

not have done so with this extreme degree of obstruction so long
as the heart’s action was tranquil. There might have been no mur-
mur whatever, nor any valvular sound from the aorta; while the
auriculo- ventricular and the pulmonary valves being healthy, there
would have been two clear sounds in the heart. Again, from the
extreme narrowing of the aortic orifice, the characteristic pulse
of aortic patency would have been wanting.

Thus we have another case of the sudden development of the
symptoms and signs of a chronic and long pre-existing disease ;
another illustration of the great fact, that the sufferings in disease,
within certain limits at all events, are much less dependent on the
mechanical than the vital condition of organs. Here there were
no symptoms of heart disease till the fever of influenza set in, and
then, the heart’s action being disturbed, the organ became unable
to carry on the circulation.

Another case of great aortic obstruction was brought forward
by Dr. Graves. The bony matter filled the sinuses of the aortic
valves, contracting the opening so that only a small quill could
be passed. The patient was a gentleman, aged 54, of active
habits; he had never felt any inconvenience nor any deviation
from a state of health till about six months before his death,
when, in walking up a hill, he was attacked with severe dysp-
noea. He afterwards found that walking even on level ground
produced great distress and a paroxysm of difficult breathing.
After each attack, however, he seemed to be quite well. About
a month before his death he was attacked with influenza, but he
was not confined to bed ; and after the disease had continued for
a fortnight he consulted Dr. Graves, who found the heart beating
violently and irregularly. A loud bellows murmur with the first
sound was audible over the whole cardiac region, and it extended
as high as the top of the sternum. He had bronchitis, with cough
and asthmatic paroxysms. His symptoms progressed with great
rapidity; complete orthopnoea set in. He became dropsical, and
died rather suddenly.

The interest of this case consisted in the sudden development
of the symptoms of a disease which must have been long in
progress. Two causes concurred in inducing the change in the
vital state of the heart which led to the fatal result: one, the

NATURE OF VALVULAR DISEASE.

155

over-exertion from walking up hill, and the other the attack of
influenza".

Although Bouillaud has suggested that under certain circum-
stances muscular fibre may be developed in the valves themselvesb,
we cannot as yet adopt his opinion, and therefore we must, in
studying the general pathology of valvular disease, consider the
valves as of a simple constitution, passive instruments, as it were,
of the powerful and complex machine to which they are subser-
vient.

It would be out of place, in a work of an essentially practical
character, to enter minutely into either the anatomical or patho-
logical nature of the different valvular diseases, particularly as
abundant information on these points may be found in the writings
of the German, British, and French investigators. But the ques-
tion as to whether we are to consider all valvular diseases not only
as arising from endocarditis, but actually as examples of this affec-
tion, in its acute or chronic form, has an important bearing on
practice, and may fairly be examined in this place.

Considered with reference to practical medicine, we may di-
vide cases of valvular disease into two classes, in one of which

* As illustrative of the effect of a general disturbing cause in developing the symp-
toms of a previously existing mechanical alteration of parts, I may allude to the case of
a gentleman who was attacked with the symptoms of influenza, then epidemic, in a se-
vere form. These having continued for throe or four days, suddenly subsided, and he then,
for the first time in his life, became affected with irritability of the bladder, so severe that
he was forced to pass urine every five or ten minutes. The urine was perfectly healthy.
These distressing symptoms continuing obstinate for a fortnight, an instrument was intro-
duced, and a large calculus discovered in the bladder. The operation of lithotrity was
performed with ultimate success.

b “ Enfin, comme certaiues parties du coeur de 1’homme ont un developpement beaucoup
moindre qne celles du cceur de bceuf, ce dernier peut nous montrer, avcc des caractdres
bien tranches, des Siemens qui n’existaient pas, ou qui n’existaient du moins qu’a
l’etat rudimentaire dans le cceur de l’homme. C’est ainsi, par example, qu’on trouve dis-
tinctement dans les valvules du coeur de boeuf des fibres musculaires, tandis qu’on n’en
aperyoit aucun vestige dans les valvules du cceur de l’homme it l'etat sain. Je dis a
l’etat sain seulement ct non a l’etat auormal, car il ne m’est pas ddmontrd qu’a ce dernier
Stat, il ne puisse se rencontrer quelques fibres musculaires dans les valvules. Je viens
d’examiner, il y a quelques jours, le coeur d’un jeune homme fortement constitute chez
lequel la valvule bicuspide etait considerablemcnt hypertrophite. Or il y 'avait dans
1 epaisseur de cette valvule quelques fibres ou filets rougeatres qui avaient uno grande
ressemblance avec des fibres musculaires trfis minces.” — Bouii.laup, Maladies du Ca:ur.

156 DISEASES OF THE VALVES OF THE HEART.

there is reason to believe that a carditis has been the first step in
the morbid process, while in the second we are without evidence
that the alteration of the valve has been in any way connected
with an inflammatory process. And it is important to observe,
that even in the first class of cases, although the morbid process
originally set up by inflammation may continue and produce suc-
cessive changes, it does not follow that the inflammatory state
persists, so that we should be often in error if we described even
this class of cases as examples of chronic endocarditis. With
the exception, perhaps, of the mere cohesion of the valves, the
pathological changes which are observed are common to both
classes. We meet in both thickening, opacities, atheromatous
and earthy deposits, contraction and permanent patency ; and
there can be little doubt, even in those cases where progressive
changes occur, that these alterations continue under the influence
of processes very different from that of inflammation.

In pointing out one of the leading errors of the pathology of the
school of Broussais, namely, that inflammation does not change
its nature, we have alluded to this subject and showed the error
into which practitioners so commonly fall, in continuing to treat
as inflammatory a disease which has long since lost that character,
or which, perhaps, never had it at all. We may apply these prin-
ciples to the treatment of many other diseases of the heart, and
especially to those of permanent insufficiency of the mitral and
aortic valves. For it is hardly possible to overstate the amount
of mischief done in many cases of chronic heart affections by
practice founded not on experience, but on a false theory, which
leads to the adoption of a general and local antiphlogistic treat-
ment.

We are not, on the other hand, to believe that there are no cir-
cumstances in which we should treat a case of valvular disease as an
inflammatory, and possibly curable affection. In cases of the ap-
pearance of a valvular murmur, in the course of or immediately
after the subsidence of an attack of pericarditis, we are to use all
proper means to remove the endocardial inflammation. So, also,
in examples of the recent development of a valvular murmur in
cases of excitement of the heart, even -without pericarditis, the same
practice is to be employed ; and experience shows that in many

NATURE OF VALVULAR DISEASE.

157

of such cases the treatment is followed by success, and organic
disease of the heart prevented. But we must be sure that the
murmur is of recent origin, and we should take care not to pro-
long our treatment beyond a justifiable period. What that period
may be it is impossible to declare with exactness, for this must
vary in each case, and the question of change or cessation of
treatment is to be determined by the experience and judgment of
the physician.

The persistence of the murmur for a week or ten days is re-
garded by Dr. Hope as indicating that the disease has passed into
the chronic stage, and this he observes may continue for several
weeks, or even months, and still be benefited by antiphlogistic
treatment. I have seen several cases in which, after a month,
there was this much evidence of a chronic inflammation, that
stimulants seemed to over-excite the heart ; but I think it probable
that, should the murmur persist for more than three or four weeks,
we should be very watchful, lest, by continuing a reducing treat-
ment, we weaken the system too much in the vain endeavour to re-
move an organic change.

When we come to consider the treatment of chronic heart
disease we may inquire how far, as in acute endocarditis, we may
employ a tonic or stimulating treatment.

It is generally believed that, organic disease being once estab-
lished, there is a progressive disorganizing process set up, which
must end in death, either by rupture of the valves, organic disease
of the remaining portions of the heart, or obstruction to the cur-
rent of the blood. And this is true in the great majority of cases.
But, as we have already seen, there is reason to believe either that
this disorganizing process may be occasionally of singular slow-
ness, so that the patient may live for many years in the enjoyment
of good, or at least tolerable health, or that the diseased action is
really arrested and the lesion becomes stationary. I have seen se-
veral cases which admitted of no other explanation. In these it
is probable that, although to a certain degree altered in their ana-
tomical condition, the valves still preserved their function, so that
there was neither any notable obstruction or insufficiency pro-
duced. And thus, with a non-excitable heart, the patient was
not only permitted to enjoy excellent health, but was even able

158 DISEASES OF THE VALVES OF THE HEART.

for years together to lead an active life and make great exertions,
while at the same time he used wine and a generous diet. It is
in such cases that improper medical interference is followed by the
worst results.

It may be stated generally that permanent patency, with or
without contraction of the orifice, is the final result of chronic
valvular disease. This is attended with various conditions of the
cavities, such as hypertrophy, dilatation, or both these conditions
combined. But we cannot lay down with any certainty what
state of the cavities will be produced, or at least found at the
termination of the case, for the changes in the muscular structure
of the heart vary not only with the amount of obstruction, but
with that of permanent patency ; so that we may find in the state
of the auricles and ventricles the effects not only of the valvular
disease in its last, but those produced in its earlier stages.

The practical physician, on being called to a case of valvular
disease, having satisfied himself of the existence of an organic
change in the mitral or aortic valves, or, as it may be, in both,
will then direct his attention to the following points, which are
the important subjects of consideration. These are :

1. To determine whether there is much obstruction to the
current of the blood.

2. To determine whether the permanent action of the heart is
augmented or depressed.

3. Whether actual enlargement of the cavities of the organ has
taken place.

4. Whether the action of the heart is regular or the contrary.

5. To ascertain, as nearly as possible, the duration of the
disease.

For it is on these points that his treatment must turn, and his
prognosis to a great degree be founded.

Thus, if he finds that although there be a manifest murmur,
say with the first sound, and in the region of the mitral valves,
yet that there neither is nor has been any symptom of dropsy
of the extremities ; if the heart’s impulse be natural, its action
regular, the pulse corresponding in force and character to the
action of the heart; the sound on percussion of the cardiac region
natural ; while the lungs show no sign of congestion, and the liver

NATURE OF VALVULAR DISEASE.

159

no evidence of enlargement, he will come to the conclusion that
the case is one not requiring much interference ; and he will be
slow to alter any of the patient’s habits if it appears that the
murmur has continued with but little change for a length of time,
and that the general health has not been impaired. He will, of
course, so far as he can do so without exciting apprehension in
the patient’s mind, direct him to avoid whatever experience in the
particular case has shown to over-excite the heart.

Again, if in a case of manifest valvular disease he finds that
oedema of the extremities has occurred ; that the patient has had
attacks of cardiac asthma, or of haemoptysis; that there is violent
action of the heart, with a pulse small or weak ; if the heart is
acting irregularly, while percussion shows that its cavities are en-
larged ; and if it appears that attacks of cardiac suffering have
been induced by various causes, such as over-exercise, hepatic
derangement, mental anxiety, or the abuse of stimulants; — he
comes to the conclusion that the cavities have suffered ; that the
disease is in all probability progressive; and his treatment and
prognosis will be shaped accordingly, for he knows that he has
to deal not only with a disease of the valves, but with its worst
consequences ; and that the chances of sudden death are much
greater than in the preceding case. Finally, the physician may
observe signs of a weakened heart. These are of two kinds, both
characteristic.

1. An extremely irregular, weak, fluttering action, with a cor-
responding pulse, rapid, unequal, irregular, and intermitting. He
will find it difficult or impossible to distinguish the first from the
second sound of the heart.

2. A morbidly slow, but generally regular action of the heart ;
the impulse feeble or wanting, unless at periods of excitement,
or when the patient is turned on the left side.

If, now, under either of these conditions he finds that the re-
spiration is often suspended, or that the patient is affected with
involuntary sighing, if there have been repeated attacks of syn-
cope or pseudo-apoplexy, and that these symptoms are mitigated
by the use of stimulants, he concludes that, with the valvular
disease, which may be mitral or aortic, or both combined, there
is a weakened state of the heart, and that in all probability the

1G0

DISEASES OF THE VALVES OF THE HEART.

disease of fatty degeneration has been established. Common sense,
to say nothing of medical experience, points out the treatment for
such a case.

From what has now been said it will be seen that, while the
diagnosis of valvular disease depends on the existence and appre-
ciation of certain physical signs, the questions of prognosis and
treatment depend upon the condition of the muscular portions of
the heart. It is true, that in cases of confirmed valvular disease,
there is danger of sudden death, generally from rupture of the
valves or tendinous chords ; but if we exclude the consideration
of the state of the heart generally, we have no means whereby to
judge of the probability of such an occurrence, for we cannot by
any special acoustic character of the valvular signs determine what
the exact anatomical change may be. Permanent patency, in-
deed, especially of the aortic valves, generally gives a characteristic
double murmur, but if we exclude this case, we find that mur-
mur attends a great variety of valvular diseases, that it may be
present in dilatation or contraction, in ossification, cartilaginous
deposits, warty excrescences, perforations, adhesions, polypoid
concretions, and aneurisms of the sinuses, and we might, perhaps,
say with truth, that every variety of murmur may be met with in
every variety of disease. As, however, so much depends on the'
condition of the cavities, and as these various diseases may exist
with or without change in the muscular portions of the heart, we
are justified in laying it down as a golden rule in practice, that
in any case of valvular disease the determination of the condition
of the auricles and ventricles is more important than that of the
seat or nature of the valvular affection.

The question, as to why in one case the cavities remain un-
changed in their mechanical and vital states, while in others
such varied conditions of disease follow the valvular affection, is
still undetermined. It may be that in those cases where the
disease has sprung from an attack of carditis, the changes in
the valve and the muscular portions of the heart proceed pan
passu, so that we might be in error in attributing the dilatations
and hypertrophy solely to the mechanical effect of the valvular
disease. It may be, that the disease, by inducing an imper-
fect arterialization of blood, causes weakening of the heart, or

NATURE OF VALVULAR DISEASE. 161

that obstruction of the coronary arteries, as Dr. Quain has shown,
may lead to the same result.

On the other hand, it appears certain that where a disorga-
nizing process has commenced in the valves, independent of any
inflammatory action, and advancing slowly even to the produc-
tion of great ossific deposits, the cavities may for a long time
remain free from disease. This will be more likely to occur in
persons whose hearts are not excitable, whose digestive and res-
piratory functions continue good, and who have escaped the dis-
turbing influence of officious medical interference, and the appre-
hensions resulting from being made aware that they are the sub-
jects of incurable disorder.

Indeed the study of cardiac pathology leads irresistibly to the
conclusion, that in valvular disease the source of irregular and ex-

cited action is to be sought for less in the condition of the valves
than in that of the heart itself. As there is no form of mere val-
vular disease which has not been found to occur with a perfectly
regular action of the heart, we must look for the cause of irregu-
larity and excitement in this affection to some other source ; and
it is to be borne in mind that the most remarkable cases of ir-
regular action of the heart are those without any lesion of the
valves. Gouty palpitation, hysterical or nervous affections, car-
diac attacks depending on sympathy with the stomach or liver,
and, lastly, the dilated and weakened condition of the heart, at-
tended with pulmonary and hepatic congestion, as in the case of
Mr. Colies, present the most striking examples, not only of ir-
regulanty, but of excited action; and these cases may occur in-
dependent of any valvular disease, or, if such exist, it is inconstant
in its seat, nature, and amount, and incompetent to explain the
condition in question. We too often find physicians giving an
' erroneous opinion from ignorance of these facts, for in their minds
i the ideas of irregular action and of valvular disease are so closely
combined, that they make the diagnosis of incurable disorder in
* cases where an emetic, an anti-nervous draught, the occurrence
of gout in the extremities, or a few doses of a mercurial, will re-
store the natural action of the heart.

A remarkable case, illustrative of what has been now said, oc-
curred in Dublin some years ago. The patient, a lady of great

VOL. I. M

162

DISEASES OF THE VALVES OF THE HEART.

intelligence, was for some years the subject of long-continued at-
tacks of violent and extraordinary palpitations, during which
the action of the heart became greatly excited, extremely irre-
gular, and attended by a loud bellows murmur, approaching to
the bruit de rape. During these attacks she was visited by se-
veral experienced physicians, who all concurred in the opinion
that some extreme and singular disease of the valves existed.
After having been the subject of this disease for several years,
she consulted me. The paroxysm was then in its decline,
after having lasted for some weeks, but the action of the heart
was irregular, with a loud and somewhat metallic murmur ap-
parently attending the first sound. She mentioned her anxiety
that I should not make up my mind as to the nature of her case
until I saw her a second time, which she arranged should be
in the course of about ten days, observing that her physicians
had not had fair play, inasmuch as they had only examined
her heart during the continuance of its excitement. The pa-
tient was perfectly persuaded that she laboured under a fatal
organic disease. 1 saw her again in about ten days; the hearts
action was perfectly tranquil, the pulse natural, and eveiy tiace
of murmur had disappeared. Several years afterwards I saw
this lady ; she was then in perfect health, and mentioned, with a
good deal of self-complacence, that she had not only puzzled all
her physicians, but had discovered her own cure, and this was in
the use of an emetic at the commencement of each attack, a
practice to which she had been led by the occurrence of acciden-
tal vomiting from the effect of some medicine which had been
administered. She then determined to take an emetic of mustard
or ipecacuanha on the supervention of each attack. The paroxysms
became less and less severe, and finally disappeared. When I last
saw her she was able to take active exercise, and the action and

sounds of the heart were natural.

A case, probably of a similar nature, was that of a young man
who was brought into hospital suffering from extraordinary ex-
citement of the heart, the action of which was so violent that the
most severe form of carditis was believed to exist. The patient
was treated with extreme but erroneous activity ; he was re-
peatedly and largely bled, mercury was freely exhibited, and all

DISEASE OF THE VALVES AT THE RIGHT SIDE.

163

other means of subduing local inflammation resorted to ; yet not
the slightest impression seemed to be made on the disease ; and as
his strength was much exhausted, while the action of the heart
continued with terrific violence, the gentleman under whose care
he was placed suspended treatment, the death of the patient being
daily expected. A draught, containing ether, laudanum, and
other ingredients, having been taken, was followed by full vomit-
ing, after which the action of the heart became regular and tran-
quil; the murmur disappeared, and convalescence was rapid and
complete.

DISEASES OF THE VALVES AT THE RIGHT SIDE OF THE HEART.

In the consideration of the question, as to how far we can de-
termine the separate existence of valvular disease at the right side,
or its co-existence with analogous affections at the left side of the
heart, we may exclude cases of congenital malformation. Keeping
in view the great object of clinical study, namely, the application
of pathological anatomy to diagnosis and practice, we find that
diseases of the valves of the pulmonary artery, and of the tricuspid
valves, are rare as compared with the analogous affections of the
left side of the heart. So great is this difference in frequency, that
in practical medicine we may confine ourselves to the diseases of
the mitral and aortic valves.

If excluding anatomical considerations, it be asked, does our
knowledge of clinical medicine justify a diagnosis of disease of the
tricuspid or the pulmonary valves? the answer must be in the
negative. This is at all events true with respect to the tricuspid
valves, and as regards those of the pulmonary artery, it can only
be said that, in the case of their permanent patency, we might
expect that the to-and-fro murmur, similar to that in the analo-
gous case of deficiency of the aortic valves, would occur, but
wanting the accompanying phenomena of the aortic murmur and
visible arterial pulsation. This condition was actually met with
in the case communicated by Dr. Gordon to the Pathological So-
ciety of Dublin, to which we shall soon refer.

Such in fact is the diagnosis of permanent patency of the pul-
monary valves given by Dr. Hope, who specially alludes to the ab-

m 2

164

DISEASES OF THE VALVES OF THE HEART.

sence of the “ jerking pulse.” But the case to which he refers is
by no means satisfactory ; and it is doubtful whether the murmurs
really proceeded from the pulmonary valves. An attack of peri-
carditis, passing through the stages of effusion and absorption, oc-
curred, from which the patient recovered and left the hospital
with the supposed pulmonic murmurs still existing. We cannot
admit the value of the remaining diagnostics given by Dr. Hope,
namely, those which depend on the pitch or key of the murmur.
Indeed this source of diagnosis must ever be fallacious, for the
tone of all cardiac murmurs depends not only on the seat and na-
ture of the disease, but also on the varying force of the heart.
And, as we have already observed, the “jerking pulse” of Dr.
Hope may be absent in the earlier stages of permanent patency
of the aortic valves.

But although we cannot make a positive diagnosis of disease
of the valves at the right side of the heart, yet this circumstance
is not a source of embarrassment at the bed-side, for we know
that such a lesion is rare, and even should physical signs exist,
as laid down by Dr. Hope, they would indicate that which is
of most importance to be known, namely, the organic nature of
the disease. If we reflect that, rare as disease of the right valves
may be, it is still more rare to find it uncomplicated with a simi-
lar affection at the left side, we need not concern ourselves as to
the importance or difficulty of its special diagnosis.

A circumstance worthy of note, as showing the difficulty of de-
termining the existence of disease in the tricuspid or pulmonary
valves, is, that when the valves on either side of the heart are so
affected as to give murmur, the normal sound of the opposite and
corresponding valves is often so masked by that murmur as to
become inaudible. If there be a mitral murmur, we lose the sound
of the tricuspid valves, and if an aortic, that of the valves of the
pulmonary artery. Reversing this, we find that the natural sounds
of the left valves may be lost or modified, so that, in many cases
of murmur, we are deprived of the advantage of comparing the
healthy valvular sound on one side with the altered sound on the
other. We have seen how doubtful all diagnostics drawn from the
situation and tone of the murmur must be; and hence the element
of probability on the one hand, and the association of symptoms and

DISEASE OF THE VALVES AT THE RIGHT SIDE.

165

signs on the other, must be our chief guides in determining the
seat of valvular disease.

As might be expected, no essential difference exists in the
anatomical character of the diseases of the right valves as com-
pared with those of the left, and the records of medicine give
examples of the different forms of thickening, contraction, ossi-
fication, and cartilaginous growths in the sigmoid and tricuspid
valves. It is laid down by authors, that the tendency to ossifica-
tion is less seen in the diseases of the right than of the left valves.
Yet, though this is in all probability true, it remains to be deter-
mined whether we may not have been misled by the greater fre-
quency of valvular disease at the left side of the heart.

“ It is especially,” says Laennec, “ in cases of preternatural
communication between the cavities of the heart, that the valves
of the right side have been found affected.” Bertin relates a
case of this kind communicated to him by Louis (Obs. 67), in
which the tricuspid valve was partly ossified, and the sigmoid
valves of the pulmonary artery formed a sort of fibrous ring hardly
two lines and a half in width. In this case there was a small
opening, two lines wide, between the right ventricle and the
origin of the aorta. In another case observed by Bertin himself
(Obs. 41) the foramen ovale was open, and the mouth of the pul-
monary artery was “ closed by a horizontal septum pierced by an
opening two and a half lines in width.” It appears probable that
arterial blood has a great influence in predisposing to depositions
of ossific matter, an opinion rendered still more probable by the
consideration of the greater frequency of these ossifications in the
valves of the left side of the hearta.

a See the case of General Wheple, quoted by Louis in his “ Memoire sur la Communi-
catione des Cavites droites avec les CavitSs Gauches du Cceur,” from the Journal de Me-
dicine, vol. ix., p. 4G8.

166

DISEASES OF THE VALVES OF THE HEART.

Case XIX. — Permanent 'patency of the Valves of the Pulmonary
Artery; open Foramen Ovale; Double murmur at the base of the
Heart not propagated into the Aorta; Absence of visible pulsa-
tion of the Arteries.

For this important case I am indebted to Dr. Gordon. A
boy, aged 12, was admitted into the Hardwicke Hospital on the
1st of March, 1851, labouring under symptoms of severe pul-
monary disease. The face was congested, and the surface cold,
his pulse extremely feeble, and the expectoration copious and
muco-purulent. A muco-crepitating rattle existed over the whole
chest, and a remarkable thrill (fremissement ) could be felt
over the entire praecordial region. Along the sternum there was
a well-marked double murmur, similar in every respect to that
observed in the ordinary case of permanently open aortic valves.
It was loudest at the base of the heart, and became less distinct
as the stethoscope was moved towards the apex, in which situation,
in fact, it ceased to be audible. There was, however, no visible
pulsation in the carotids, subclavian, or radial arteries, nor any
murmur or fremitus in those vessels. In the inter-scapular region
the double murmur could be heard, although its intensity was
greatly diminished.

This patient had been considered healthy until he had at-
tained the age of seven years, when, after an attack ol measles, he
continued to suffer from cough, dyspnoea, and palpitation, in-
creased by the least exertion. During his stay in hospital lie was
much relieved from the bronchitis, yet though the action of the
heart became less violent, the fremitus and double murmur con-
tinued unaltered in extent and intensity.

In this case the existence of the purring thrill over so large a
surface, taken in connexion with the anomalous circumstances of
the case, led Dr. Gordon to make the diagnosis of an open foramen
ovale.

On dissection the heart was found but little enlarged, an oval
opening, the longest diameter of which was about three-quarters
of an inch, was found in the inter-auricular septum. The valves
of the heart were generally healthy, with the exception of those

DISEASE OF THE VALVES AT THE RIGHT SIDE. 1G7

of the pulmonary artery. These valves were thickened, shortened,
and opaque, leaving a gaping orifice through which water passed
freely when poured into the artery. This case is another illustration
of the doctrine, that organic disease of the valves of the right side
of the heart is most often met with when a preternatural commu-
nication exists between the systemic and pulmonary sides of the
organ.

So far as this single case goes, it justifies the diagnosis of
permanently patent valves of the pulmonary artery, which has
been suggested rather than established by Dr. Hope and others,
namely, that there should exist a double murmur at the base of
the heart similar to that in aortic patency, yet without the propa-
gation of murmur into the large vessels, or the throbbing and
visible pulsation of the arteries.

On the subject of insufficiency of the valves of the pulmonary
artery, Dr. Walshe observes that, “ pulsation of the arteries would
not accompany the double murmur of patency of the pulmonary
valves.” “By a singular fatality,” he remarks, “while a certain
number of examples of such destructive disease or insufficiency
of the valves as must have led to full regurgitation have been ob-
served post mortem in this country, in not one that I know of had
the physical signs been clinically established. Theoretically the
effects on the systemic and cerebral capillary circulation must
be most serious, and a sensation of dyspnoea, arising from the
smallness of the quantity of blood actually reaching the lungs by
each systole might, unless the force of habit would counteract this
influence, be expected”11.

The case now given will supply to a certain degree the de-
ficiency complained of by Dr. Walshe. But yet we cannot at-
tribute the whole of the physical signs in this case to the perma-
nent patency of the pulmonary valves, for the purring thrill may
be considered to have arisen from the defective condition of the
auricular septum. We do not usually find this sign connected
with aortic patency, and it is hence unlikely that it would occur
in the analogous condition of the pulmonary artery.

There is another form of insufficiency of the valves which

* A Practical Treatise on Diseases of the Lungs anil Heart. London, 1851.

168

DISEASES OF THE VALVES OF THE HEART.

arises not from disease of the valves themselves, hut from dilata-
tion of the cavities when carried beyond a certain point. It is
probable that this condition will be found more frequently at the
right side, where it may affect both orifices, and be attended with
dilatation of the pulmonary artery. The case now given is illus-
trative not only of these conditions, but is one of those in which
the grounds for a precise diagnosis were manifestly wanting, inas-
much as the physical signs might have been held to indicate a
variety of organic lesions.

Case XX. — Dilatation of all the Cavities of the Heart, of the Pul-
monary Artery, and of the Aorta; Insufficiency of the Auriculo-
Ventricular Valves on both sides ; Fremitus over the Heart with
a musical murmur attending the second sound; Replacement of
the systolic sound on the left side by a soft murmur.

J. Loughlin, aged 34, was admitted into my wards in Novem-
ber, 1847, labouring under general dropsy and symptoms of car-
diac disease. This man had enjoyed good health for the last six
years, and during that time had been temperate. About six
months before admission he began to complain of cough and
dyspnoea, attended with palpitation, which latter symptom occur-
red without any assignable cause. The dropsical condition com-
menced three months previously.

On admission his countenance was pale and expressive of
great anxiety, and his whole appearance indicated congestion.
General anasarca and ascites existed. The chest was clear on per-
cussion, except in the region of the heart, which was dull to a much
greater extent than natural. The jugular veins were distended and
visibly pulsating. Bronchial rales were found over the chest.
The heart’s impulse was feeble, but it was attended with a most
intense and extended fremitus, and a loud musical murmur syn-
chronous with the second sound. To the left of the nipple a soft
and indistinct murmur replaced the first sound. The radial pulse
was very feeble, and beat 100 in the minute.

This patient sank rapidly. The heart was found to be en-
larged to more than twice its natural volume; this increase of

size was principally owing to dilatation of the cavities. Both

DISEASE OF THE VALVES AT THE RIGHT SIDE. 169

auricles and the right ventricle were much enlarged. The left
auricle was twice its natural size, with some hypertrophy. The
aorta was of a bright red colour, and thickly studded with athe-
romatous concretions. It was dilated, but the orifice was quite
perfect ; the valves, though a little thickened, being competent to
close the opening completely.

The right auriculo-ventricular opening admitted of five fingers
being passed through it; its circumference measured six inches
and a quarter. The valves were healthy, but evidently incompe-
tent to close the orifice. The circumference of the pulmonary
artery was not less than four inches ; the valves healthy ; four
fingers could be passed through the left auriculo-ventricular open-
ing ; its valves were healthy, but its circumference measured five
inches ; the valves seemed insufficient to close the opening. The
circumference of the aortic orifice was three inches and three
quarters.

In this case the greatest amount of dilatation of the orifices
seemed to be on the right side of the heart ; thus, —

The pulmonary artery measured four inches in circumference ;
the right auriculo-ventricular opening, six inches and a quarter ;
the aortic opening, three inches and a quarter ; and the left auriculo-
ventricular, five inches.

We have in this singular case a combination of circumstances
which would justify the withholding an opinion as to the exact
nature of the disease. The murmur with the second sound, we
know, is generally indicative of aortic patency, but the character
of pulse was wanting. It was small and weak, instead of being
large and jerking. And, again, the remarkable fremitus and the
; jugular dilatation indicated something in addition to disease of
the aortic valves.

To analyse the phenomena in such a case, so as to determine
which of them were owing to the dilatation of the pulmonary ar-
1 tery, and which to the enlargement of the auriculo-ventricular
openings, would be impossible in the present state of our know-
1 ledge.

According to Dr. Hope, dilatation of the pulmonary artery is
one of the rarest diseases incident to man. One case only, in
which this disease was revealed by dissection, is given by Dr. Hope,

170

DISEASES OF THE VALVES OF THE HEART.

the circumference of the artery being nearly five inches. I believe,
however, that dilatations of this vessel, though of less amount, are
not unfrequent. I have, on several occasions, found dilatation of
the artery in examples of Laennec’s emphysema, and it is remark-
able that no unusual phenomenon attended these cases.

We cannot, however, admit the rules for the diagnosis of this
affection as laid down by Dr. Hope. Indeed, the whole of his
statements on this point show the danger of attempting to estab-
lish rules for the exact diagnosis of the rarer diseases of the
heart.

It may be asked, however, are we yet in a position to make
the diagnosis of dilatation of the pulmonary artery. Here is a
disease which is certainly one of much more rare occurrence than
dilatation of the aorta. Can we, in a case where the dilatation is
so great as to cause physical signs, certainly distinguish it from
true aneurism of the aorta? I believe that in the present state
of our knowledge we cannot safely make this diagnosis. I cer-
tainly would not venture to do so, even if the case presented all
the signs given by Dr. Hope. So great is the variety in cases of
aortic dilatation, that we cannot declare against the existence of
disease in the aorta from the absence of any one of the signs of
aneurism of that vessel, or the presence of any one of those which
are supposed to indicate disease in the pulmonary artery. Thus
aortic aneurism may cause a pulsation between the second and
third left ribs with or without murmur. Large sacculated aneu-
risms of the arch of the aorta, too, may exist without external
tumour or murmur, and without tremor, pulsation, or murmur,
above either clavicle.

This case is illustrative of the principles already laid down as
to the practical application of diagnosis. Here there was no dif-
ficulty in determining that the disease was organic, and that the
heart was in a dilated and weakened state. The age and sex of
the patient, the history of the case, the supervention of dropsy, all
pointed out that a disease, not likely to be a merely nervous affec-
tion, existed. The feeble impulse, the pulsation, and distention of
the jugular veins, were indicative of a weakened heart with di-
lated right cavities, while the intense fremitus and musical mur-
mur, although not propagated into the arteries, pointed out some

DISEASE OF THE VALVES AT THE LEFT SIDE. 171

important valvular lesion. So far, all that appeared useful to be
known in this case was easily arrived at. The vital state of the
heart was manifest, and the murmur obviously not an anasmic, not
a nervous, but really an organic murmur.

But in such a case, to declare what was the exact cause of
the fremitus and musical murmur with the second sound per-
ceived over the whole heart, would have been to enter on a ques-
tion incapable of solution, and one probably of no practical im-
portance. We might have long and ingeniously speculated on
whether they proceeded from disease of this or that valve, whether
they indicated lesion on one or both sides of the heart, or whether
there was any preternatural communication between the cavities,
— without coming to any useful conclusion. Who could declare
the exact state of the valves in this case, or say were they ossified,
contracted, dilated, or permanently patent? Was there a dis-
secting aneurism, or did a coagulum interfere with the action of
the heart? Why was the first sound on the left side replaced
by a soft murmur, and what indications existed of the diseased
condition of the pulmonary artery and the aorta?

If we consider that in chronic disease of the heart, when it is
attended with symptoms and disturbance of action, with visceral
congestion and dropsy, there is generally a complicated condition ;
that more than one set of valves is probably engaged, even though
the physical signs seem to point out that but a single set are
affected ; and reflect that it is not always the more important
lesion that causes the most prominent physical sign ; and that the
signs of disease on one side of the heart may mask the natural
phenomena on the other, — we must be slow in giving a special or
an exclusive diagnosis1.

DISEASES OF THE VALVES AT THE LEFT SIDE OF THE HEART.

It has been already observed that, if we consider valvular
disease in relation to practical medicine, the affections of the left

* % exclusive diagnosis I mean that which declares, in an organic disease, that such
and such portions of the heart are free from lesion, because none of the physical signs
arc present which usually attend the affections of these parts.

172

DISEASES OF THE VALVES OF THE HEART.

valves demand our principal attention. This arises from the fol-
lowing circumstances :

1. That they are so much more frequent.

2. That a certain proportion of them are in the first instance
inflammatory, and therefore capable of being removed or con-
trolled by medical treatment.

3. That they are liable to arise in the course of diseases which
are of common occurrence.

4. That though, when established, they may exist for a great
length of time without causing local or general disturbance, yet
that they lead to disease of all the cavities of the heart, and give rise
to special affections of the lung and brain.

5. That they more frequently terminate in sudden death than
the affections of the right side.

It is easy to understand, when the complicated nature of the
auriculo-ventricular valves is considered, which show an appa-
ratus partly vital and partly mechanical, that an imperfect state
of the valves may be induced by many causes besides inflammation.
All the morbid processes that affect a serous structure by deposi-
tion, thickening, contraction, hypertrophy, atrophy, and transfor-
mation into an earthy or ossific state, may be found to cause
imperfection of the valves. Again, whatever interferes with the
action of the papillary muscles may impair that of the valves, as
by over-action on one hand, and debility on the other. And
again, the diseases of tendons by which, as Dr. Law has noticed,
they are rendered brittle, probably bear a part in many cases
of valvular disease. Lastly, coagula stretching through the ori-
fices, and probably also purulent cysts, will impede the action of
the valves'1.

Thus, if we include inflammation, we have not less than twelve
pathological conditions which may induce valvular lesion. And
if the question be asked, can we in any given case, with the early
history of which we are unacquainted, determine which of these

» In the case of purulent cysts in the heart, consequent on plilebitic inflammation,
which has been already given, one of the largest of the cysts was found behind the su-
perior lamina of the mitral valve, which was, as it were, stretched over it, and rendered
convex towards the ventricle. The specimen is preserved in the Museum of the Richmond
Hospital.

DISEASE OF THE VALVES AT THE LEFT SIDE.

173

c causes has given rise to the disease, or how many of them are
then concurrently producing it? the answer must be in the ne-
!' _ gative.

The ultimate result of disease of the mitral valves is to destroy
t their mechanical function. And thus, from many causes, a perma-
rnently open state of the orifice is established. The period at which
t this change takes place will of course vary in different cases, but
\we find it with dilatation and with contraction of the opening.
I It appears more than probable that, when once this change in the
r mechanical state of the opening has occurred, that it remains per-
rmanent.

The views of Mr. O’Ferrall on this subject have been already
aalluded toa. In explaining the cessation of valvular murmur,
Twhile the organic disease continues, he advances the opinion that
t the regurgitation which had existed at the earlier periods, from
t the shortening of the valves, ceases in consequence of the contrac-
t tion of the opening, so that their shortened laminae become com-
fpetent to close the diminished orifice. The order of phenomena
would then be as follows :

1. Shortening of the mitral valves, causing regurgitation and
n murmur.

2. Contraction of the auriculo-ventricular orifice.

3. Cessation of regurgitation and of murmur, from the di-
nminished orifice becoming adapted to the valves.

He observes : “ If this, then, be the order in which the changes
; succeed to each other, is it not reasonable to suppose that shortening
of the mitral valves most commonly anticipates the contraction of
the orifice; and consequently that regurgitant disease in this part
: commonly precedes the phenomena of contraction.”

I have had no opportunity of observing the arrest of regurgita-
' tion under the conditions described by Mr. O’Ferrall, yet, without
denying the possibility of such an occurrence, we must believe that
the re-establishment of the function of the valves is not necessary
to cause cessation of murmur in a case of progressive disease. It
appears rather that it may occur in a contracted yet permanently
open orifice, as in the cases I have detailed. And, so far as we
know at present, the conditions capable of inducing this cessation

1 See the Observations on the Nature of Valvular Diseases.

174

DISEASES OF THE VALVES OF THE HEART.

of murmur are, smoothness of the edges of the orifice, attended
with contraction.

SYMPTOMS OF DISEASE OF THE MITRAL VALVES.

Although detailed accounts of the symptoms of mitral valve
disease have been given by various writers, yet it is certain that
the symptoms in question belong to complicated rather than to
simple disease of the valves. And the complication is twofold,
namely, that of a functional and an organic disease of the cavities
of the heart. We know of no symptoms proper to mere disease
of the mitral valves, and we have seen that these valves may have
been long affected without any symptom that could lead to a
suspicion of disease. And in most cases, when the so-called cha-
racteristic symptom of permanent irregularity of the heart is found,
we may believe that organic change has taken place in the cavities
of the organ; for an impulse which does not differ from that of
health, a perfectly regular action, a pulse presenting nothing pe-
culiar in its volume, rate, force, or rhythm, are commonly to be met
with in cases where a distinct mitral murmur exists, and in which
for many years the patient has shown no symptoms of disease of
the heart, and has been able to use long-continued and fatiguing
exercise.

In another set of cases we find this absence of symptoms,
unless under the influence of fatigue or excitement, when in-
creased action, palpitation, and dyspnoea, occur, but yet subside
after a short period of time. And we may meet with cases of long-
continued mitral murmur in which paroxysms of pain and cardiac
distress are more likely to occur when the system is at rest than
when the heart is excited. Such a condition may last for a great
length of time, and with extensive and complicated disease, not
only of the valves but of the cavities of the heart, as shown by
continued mitral murmur and fremitus, and by the signs of en-
larged cavities. The general health may be excellent, but the
patient is liable to attacks of stinging pains in the region of the
heart, which generally come on when the system is at rest, and
are often absent during, and for some time subsequent to, the pe-
riods of active exertion.

SYMPTOMS OF DISEASE OF THE MITRAL VALVES. 175

We may safely hold that the symptoms of mitral valve disease,
: as laid down by authors, are those, not of simple change of the
orifice, hut of the complication of this state, with lesion of the
i muscular portions of the heart; and this, after all, is but repeating
i the doctrine of Laennec, which has been but scantily acknow-
ledged even by the writers who adopt his views.

A contracted pulse, in cases where the orifice is narrowed, may
! be observed, but not with such constancy or character as to entitle
i the symptom to much consideration. And with respect to irregu-
1 larity, experience shows that this condition is more intimately
t connected with lesion of the muscles than of the valves of the heart.
In valvular disease, unattended by serious obstruction and uncom-
j plicated with functional or organic lesion of the cavities, there is
1 nothing which should cause irregularity of pulse. And it is pro-
1 bable that, were we to divide cases of valvular disease into two
( classes, namely , those with and those without irregularity, the latter
' would be found by far the more numerous.

There are, then, no special symptoms of disease of the mitral
' valves which distinguish it from other affections of the heart,
i for there is a class of symptoms common to almost all these affec-
t tions. Nor can we admit that there are distinctive symptoms of
’ valvular lesion of any kind, nor that, even when the disease is com-
1 bined with hypertrophy and dilatation, irregularity of the heart
i is always present ; for even under these circumstances the heart’s
action may be regular.

A violent impulse, while the pulse is small and weak, affords,
i according to Hope, one of the strongest indications of valvular dis-
( ease. Yet these circumstances may occur in cases where no such
l lesion exists. They are met with in hypertrophy and dilatation
of the right ventricle and auricle, in nervous affections, in anaemia,
c chlorosis, and occasionally in typhus fever.

Finally, we cannot declare the existence of disease of the
h valves from any character of the pain which may attend this
lesion ; and, even in the cases where it is present, no distinction
has been observed between the pain in mitral, as compared with
that in aortic valve disease

But although pain of a decided nature, often severe ahd of a

176

DISEASES OF THE VALVES OF THE HEART.

lancinating, pungent character, varying in its seat and extent in
different patients, or at different times in the same person, some-
times stretching into the arm, as in angina pectoris, and at others
singularly fugitive, and affecting successively various portions of
the front of the chest, is a symptom of great importance and fre-
quent occurrence in valvular disease ; it is still to be determined
whether it is indicative of simple valvular lesion, or of the com-
bination with some form of hypertrophy. That it is more often
met with in the latter case appears certain. I do not remember
any instance of this cardiac pain where the disease was only to
be discovered by auscultation, where the heart’s action was tran-
quil, the pulse regular, and the signs of hypertrophy absent.

Nor is it yet determined what the nature of this pain may be,
nor how far mere disease of the valves assists in its production.
We may fairly doubt whether any real connexion, in the relation
of cause and effect, exists between it and valvular disease at all;
no matter whether we look on the latter affection in reference to
its mechanical or vital effects. Dr. Hope believes that this pain is
in general occasioned by the inelasticity of the ossified or other-
wise indurated parts, which will not stretch equally with the other
portions of the heart when the organ is labouring under palpita-
tion or engorgement11.

If this opinion be well founded, we should expect that in
any case in which these pains occurred, they would be induced
by excitement of the heart. Yet it is not always so. And in
certain cases we may not only see that the pains are not caused
by active exercise, but that they are absent when the heart is un-
usually excited. I have long observed a case of this kind. The
patient, when a child, was attacked with rheumatic fever and in-
flammation of the heart, in all probability an endo-pericarditis.
On the subsidence of the fever, signs of confirmed valvular disease
were established ; it was at this time I first saw him ; and since
that period, now more than ten years ago, he has been under my

a See Dr. Hope’s Treatise, p. 356. The author observes that, “when inflammation
of the interior of the heart exists it may occasion pain, but those authors have been un-
questionably wrong who have considered inflammation to bo the sole cause of pain, and
have therefore assumed this symptom as a proof of the inflammatory nature of disease of
the valves.”

SYMPTOMS OF DISEASE OF THE MITRAL VALVES.

177

care. He has grown up, and is a tall and powerfully developed
man, although during the whole of this time the heart has exhi-
bited manifest symptoms and signs of a great amount of valvular
disease. This patient has also had repeated attacks of rheumatism,
but of a mitigated character. The following conditions have been
always present :

1. The impulse strong and extended, conveying the idea of
a greatly enlarged heart; the pulse, however, not corresponding

1 1 either in volume or force.

2. A purring thrill in the mammary region.

3. A loud and rough murmur with the first sound of the
heart, having its greatest intensity to the left of the nipple, but
heard over a large portion of the front of the chest.

4. The action of the arteries natural.

Now this patient has been for years liable to paroxysms of
i i cardiac pain, of a well-marked and often distressing character, yet
1 he has uniformily found that these pains came on when the ac-
i i tion of his heart was most tranquil ; and that whenever he suffered
It from excitement of the heart, induced by derangement of the di-
i gestive system or by the modified rheumatic attacks, he became
1 free from pain. On many occasions, when warned against taking
I too violent horse-exercise, he has declared that the best mode of
i relieving the pains was to take a smart gallop on his horse and ex-
c cite the heart into rapid action. It is difficult to explain these
facts if we attribute pain to the mechanical resistance ofindu-
i rated valves ; but it is more easy to reconcile them with the doc-
t trine of engorgement spoken of by Hope, if we suppose that this
engorgement was for the time lessened or removed by a more vi-
: gorous action of the heart.

Upon the whole, when we consider that pain of the heart is
- so commonly present without organic disease ; that there are so
r many cases oflong-continued valvular murmur, in which pain has
: been always absent ; and lastly, that pain is in general so little
i associated with old mechanical changes of organs, and that it
may occur in mere hypertrophy and dilatation of the heart ; — the
conclusion presses on us, that these cardiac pains are not necessa-
rily connected with valvular disease, but are rather examples of

VOL. I. N

178

DISEASES S>F THE VALVES OF THE HEART.

some form of neuralgia, which may exist with or without organic
disease of the heart.

The effect of mitral obstruction on the pulmonary circulation
is twofold. It may produce a partial or general congestion, or
an actual effusion of blood. In the first case we may observe
the symptoms, and perhaps the signs of localized pulmonary
apoplexy, while in the second, those of a more general congestion,
with or without bronchitis, are noticed.

It appears probable that the production of a disease of the
answering to the description of Laennec’s circumscribed
pulmonary apoplexy, is the first and most common result of the
valvular disease ; while the second, namely, the general, though
less intense congestion, is observed either during a paroxysm of
cardiac asthma, or only towards the close of the case.

To explain the occurrence of isolated apoplectic effusions in
the lungs of persons labouring under mitral obstruction is diffi-
cult. We find in various portions of the lung well-defined effu-
sions of blood, of a size varying from that of a pea to that of
a pullet’s egg. Some have described this affection under the
name of the nodular pulmonary apoplexy. In these cases, as dis-
tinguished from more general effusions, Hasse believes that the
fluid is merely poured into the air-cells, without any rupture,
while the adjacent texture remains healthy. This author states,
that he found the whole of one lobe thus affected. Such an
extent of disease, however, must be of rare occurrence.

But we would be in error if we supposed that this peculiar
form of pulmonary apoplexy was dependent solely on mitral ob-
struction, for although the statements of authors, as to its con-
nexion with disease of the heart, are not as accurate as could be
wished, there is reason to believe that, while it may arise as a
consequence of narrowing of the left auriculo-ventricular orifice,
so also it may be produced, to use the words of Hasse, by hyper-
trophy of the right ventricle, causing an undue afflux of blood to
the lunga.

1 Op. Cit. p. 247, Dr. Swaine’s Translation. See also Allan Burn’s Observations on
Diseases of the Heart, 1809, as noticed in an important note by Dr. Forbes, in his trans-
lation of the work of Laennec, Art. Pulmonary Apoplexy. Dr. Townsend’s Observations

PHYSICAL SIGNS OF DISEASE OF THE MITRAL VALVES. 179

Various affections of remote organs have been attributed to
disease of the left auriculo-ventricular valves, which, however,
it will be better to consider when we speak of the general effects
of diseases of the heart.

From what has been now stated it appears, that we are unable
by any study of symptoms alone, to determine the existence of mi-
tral valve disease, either when it is uncomplicated, or when altera-
tions of the cavities have occurred. In the first case, as we have
seen, the disease may exist without symptoms at all, and in the
second, those symptoms supposed to be characteristic are really
not so, but are more or less common to many diseases of the
heart.

PHYSICAL SIGNS OF DISEASE OF THE MITRAL VALVES.

We have already drawn in outline the character of these
signs. The presence of a murmur which may be soft, hoarse, or
musical, attending the systole of the heart, loudest towards the
apex, and at the left side, and not propagated into the arterial
trunks, is the chief indication of the disease. This murmur may
be accompanied by a fremitus, and in many instances the second
sound is unaffected.

In such a case, as has been already remarked, we might, taking
other circumstances into consideration, make the diagnosis of
organic disease of the mitral valves with a great degree of cer-
tainty.

But such examples as the foregoing are more often pictured
in systematic works than met with at the bedside ; for here the
observer who has taken books alone for his guides will meet
with difficulties for which he is not prepared. A striking defect
of many modern works on diseases of the heart is, that the authors
assume not only that each disease of the heart has its special phe-
nomena, but that no difficulty attends the determination of those
accompanying circumstances, by which the seat of the abnormal
signs is to be settled. The real difficulties of the subject have
not been fully stated, and hence one cause of the differences of

in the Cyclopaedia of Practical Medicine, vol. i. p. 128, may be consulted. Drs. Hope
and Walshc concur in attributing the nodular pulmonary apoplexy, in most cases, to
disease of tho mitral orifice.

N 2

180 DISEASES OF THE VALVES OF THE HEAKT.

opinion as to the exact nature of a particular case. It happens for-
tunately, that if the general diagnosis of organic disease be correct,
the special diagnosis is of little value. This point has been already
insisted on.

But to return to the subject in hand. We read that a murmur
with the first sound, under certain circumstances, indicates lesion
of the mitral valves. And again, that a murmur with the second
sound has this or that value. All this may be very true, but is
it always easy to determine which of the sounds is the first, and
which the second? Every candid observer must answer this ques-
tion in the negative. In certain cases of weakened hearts actino-
rapidly and irregularly, it is often scarcely possible to determine
the point. Again, even where the pulsations of the heart are not
much increased in rapidity, it sometimes, when a loud murmur
exists, becomes difficult to say with which sound the murmur is
associated. The murmur may mask not only the sound with which
it is properly synchronous, but also that with which it has no con-
nexion ; so that in some cases even of regularly acting hearts,
with a distinct systolic impulse, and the back stroke with the
second sound, nothing is to be heard but one loud murmur.

So great is the difficulty in some cases, that we cannot resist
altering our opinions from day to day, as to which is the first,
and which the second sound.

Again, many of the rules laid down for differential diagnosis
depend on the transmission or non-transmission of the valvular
sounds into the aorta. But this question, which, as discussed
in books, seems of easy solution, is often, in reality, difficult to
decide. For in many cases of mitral valve disease the murmur is
found to extend along the sternum, and under both clavicles.
Under these circumstances, although by ascertaining the point of
maximum loudness to be towards the apex and to the left side,
we may infer that the murmur extending over the chest is pro-
bably the mitral sound modified by distance, yet who can say that
there is really no murmur in the aorta, especially when we know
that disease of the aortic opening may exist, and yet the second
sound remain unaffected ?

But does the state of our knowledge of the signs of cardiac
disease, and of vital acoustics in general, justify us in making an

PHYSICAL SIGNS OF DISEASES OF THE MITBAL VALVES. 181

absolutely positive diagnosis, not only of the seat of the murmur,
but of the nature of the disease, and the caliber of the orifice ?
This question must be answered in the negative, and we must
receive as unproved and calculated to ^hrow discredit on the
science of diagnosis all those rules and descriptions of special
phenomena, supposed to apply not only to almost every patholo-
gical change of the valves, but every possible combination ol
these changes. In the ordinary cases of mitral murmur we can-
not say whether the murmur is “ constrictive” or “ regurgitant,”
or constrictive and regurgitant; and we must reject a large pro-
portion of descriptions of phenomena which, although the changes
they are supposed to indicate be familiar to anatomists, are them-
selves of doubtful value. To the inexperienced the detailed de-
scriptions of such phenomena as the intensification of the sounds
of the pulmonary valves", of constrictive murmurs as distinguished
from non-constrictive, of associations of different murmurs at the
opposite sides of the heart; of pre-systolic and post-systolic, pre-
diastolic and post-diastolic murmurs, act injuriously ; first, by
conveying the idea that the separate existence of these pheno-
mena is certain ; and that their diagnostic value is established ; and
secondly, by diverting attention from the great object, which —
it cannot be too often repeated — is to ascertain if the murmur
proceeds from an organic cause ; and again, to determine the vital
and physical state of the cavities of the heart.

On this subject Dr. Graves’s observations are of great value.
“The chief means,” says this true physician, “ of distinguishing
which of the valves of the heart is diseased is derived from the
supposed direction of the sound. This is by far the most useful
diagnostic mark we possess, and by it we may often, but not
always, distinguish disease of the right from disease of the left
side of the heart, and we may even occasionally, though not often,

a This is one of the signs noticed by Skoda as indicating constriction of the mitral
opening, and giving a diagnostic between this affection and simple roughening of the au-
ricular face of the valve. This doctrine, for the reasons already specified, cannot he re-
ceived, and it has never happened to mo to observe any augmentation of the second
sound in cases of mitral murmur. Dr. Walshe observes that, “ the least reflection on the
unfrequency of direct mitral murmur, and on its frequent accompaniment, when present,
by regurgitant mitral disease will show, how hazardous the assertion of Skoda is.” —
Practical Treatise on the Diseases of the Lungs and Heart , p. 226.

182

DISEASES OF THE VALVES OF THE HEART.

distinguish diseases of the auriculo-ventricular from those of the
semilunar valves. Another means of diagnosis much relied on is
taken from the morbid sound accompanying, and, therefore, being
a perversion of the first or of the second sound of the heart; but
as at each motion of the heart, valves are opened and valves are
closed, a morbid sound may be produced by any change of struc-
ture which permanently prevents the complete opening or shut-
ting of the valves ; and consequently the same sound may arise
either from changes of structure obstructing the advancing blood,
or from changes permitting regurgitation ; — in other words, it is
impossible to judge at the moment a sound occurs, which of these
is its cause”a.

A case is given by Dr. Graves, which, however we may in-
terpret it, is a good illustration of the accidents, so to speak, which
may be in store for those who are over-confident in special diag-
nosis. A man of intemperate habits had for eight years laboured
under palpitation and dyspnoea. When admitted into hospital
he was emaciated and dropsical; pulse 94, regular; and there was
no visible pulsation, thrill, or bellows murmur in the arteries of
the neck or upper extremities.

The right side of the chest was dull, with weak and crepitat-
ing respiratory murmur. Loud respiration, free from any rale ,
was heard over the left side, which was clear on percussion. The
impulse of the heart was strong and rather diffused; the sounds
loud, the first being accompanied by a bellows murmur audible
all over the cardiac region, but remarkably intense to the left of
the nipple. This did not ascend along the course of the aorta,
nor was it accompanied by any fremitus.

This patient remained for five weeks under observation, when
he sank, no change having taken place in the physical signs of
the heart. The right lung was found studded with tubercle, the
left was healthy. The heart was hypertrophied, and the peri-
cardium universally adherent, the union being effected by a dense
cellular membrane. There was not the slightest trace of recently
deposited lymph. All the valves of the heart were perfectly healthy.
The ascending portion ol the aorta was dilated, and its inner sur-

* Clinical Medicine, p. 922.

disease of the mitral and aortic valves.

183

face rough and scabrous from an abundant deposition of earthy
matter. °The arch and descending aorta were healthy, and the
aortic valves perfect.

Dr. Graves inquires how could such a case as this be distin-
guished from one of mitral valve disease, and compares it with an
example of mitral contraction given by Dr. Budda, in which the
physical signs were nearly identical.

Although difficult of explanation, this case is one of great value,
as shewing the necessity of caution even when the best marked
signs of local disease may exist. It does not, however, appear certain
that the cause of the murmur was the diseased state of the aorta,
for it is difficult to understand why a murmur thus produced should
not be propagated in the course of the current of blood, while in
the opposite direction it was loudly audible. The murmur, though
not produced by valvular disease, may have arisen from other
causes, perhaps some alteration of the form of the ventricle conse-
quent on the adhesion of the pericardium, perhaps also from the
state of the blood giving rise to an anaemic murmur in the heart.

COMBINATIONS OF DISEASE OF THE MITRAL VALVES.

Of these by far the most common is disease of the aortic valves.
In this combination the relative amount of each affection varies
considerably. Thus, in a case recorded by Dr. Lawb, the disease
of the mitral valves did not go beyond a slight thickening of their
margins, while the aortic valves were greatly altered, so as to ren-
der the opening* permanently patent. Two of the valves were
thickened, and the margin of the third turned towards the ven-
tricle so as to resemble the state of the lower lid in cases of ectro-
pium. The apex of the heart was formed principally by the left
ventricle.

Another case of this combination has been recorded by Dr.
Law. The patient, twenty-four years of age, had led an irregular
life, and was attacked with spitting of blood, dyspnoea, and cough,
which led to the supposition that he was labouring under phthisis.
A mucous rattle existed over the chest. The impulse of the heart

* Clinical Remarks at King’s College Hospital. Medical Gazette, January 7, 1842.

h Transactions of the Pathological Society of Dublin.

184 DISEASES OF THE VALVES OF THE HEART.

was considerable, a double bellows sound was audible at the
lower part of the sternum, and a single murmur at the left mam-
mary region. Pie left the hospital, but was re-admitted in the
following condition. He appeared stupid and listless ; his face
was flushed, and the temporal arteries were throbbing, yet there
was less action of the heart than previously, and the abnormal
sounds were no longer audible. He replied but slowly to ques-
tions; he was partially paralysed on one side; and had convul-
sive fits during the night previous to his admission. After the
lapse of about ten days he suddenly became comatose, and died
almost immediately.

The heart exhibited a double lesion, the aortic and mitral
valves being diseased. The natural form of the heart was altered,
its apex having become rounded. A quantity of greyish puru-
lent matter was found covering the inferior surface of the brain.
The left corpus striatum was softened, as was also the adjoining
cerebral substance.

The diseased condition of the brain in this case was considered
by Ur. Law to have arisen from defective arterial supply, and to
this subject we shall hereafter return. Considered with reference
to the physical diagnosis of valvular disease, it is to be noted, that
two distinct kinds of murmur were observed, differing both in na-
ture and seat ; one, a double murmur heard at the inferior ster-
nal region ; the other, a single murmur evident to the left of the
nipple. The first of these was obviously the murmur of the per-
manently patent aortic opening, and the second indicative of
disease of the mitral valves. That such a combination would
justify the diagnosis of the double lesion appears pretty certain,
and we shall just now record a case which occurred lately in the
Meath Hospital, confirming the diagnosis as given by Dr. Law.

But we must not expect to find both mitral and aortic mur-
murs in these cases of combination, for it may be, that from excess
of disease, as has been formerly explained, the mitral orifice be-
comes so altered as to give no murmur during the passage of the
blood. This probably occurred in the following important case, for
which I am indebted to Dr. Adams.

DISEASE OF THE MITRAL AND AORTIC VALVES.

185

Case XXI. Contraction of the Mitral and Aortic openings; Thick-

ening and Dilatation of the left Ventricle and Auricle , the lining
membrane of the latter being thickened and opaque ; Great dilata-
tion of the pulmonary veins; Occlusion of the contracted Mitral
orifice by a Coagulum.

A gentleman, aged 40, had, fifteen years previous to his death,
suffered from an attack of rheumatic fever. His countenance
gave no indication of his being the subject of disease of the heart.
During the last six months of his life he found that riding on
horseback, or ascending an eminence, induced dyspnoea, and
he gradually became incapable of taking any exercise beyond
that of very moderate walking. He had little or no cough. The
mere exertion of dressing in the morning produced great exhaus-
tion, a symptom frequently observed in such cases. The pulse at
the wrist was weak and irregular, while the action of the heart
was very strong, especially towards the apex, and its pulsations
seemed more numerous than those of the radial artery. Percus-
sion gave a dull sound over the anterior portion of the left side from
the second rib downwards. The veins in the neck were not tur-
gid, nor did they ever become so, nor were there any symptoms
of dropsy or emaciation.

A bellows murmur, very distinct towards the apex of the heart,
but also extending along the great vessels, could be heard ; and
the diagnosis arrived at was that there was contraction of the
left auriculo- ventricular and the aortic orifices.

The patient laboured under a presentiment that his death would
be sudden, and this was verified by the result. On the day before
his death he appeared to be in excellent health ; in the even-
ing he took a walk with his children, and remained out till ele-
ven ‘at night. At three o’clock next morning he experienced a
sensation of faintishness, and complained of feeling cold, and at
daylight was found dead in his bed. His lips were livid, and the
the cause of death seemed to have been asphyxia.

The heart was found much enlarged, the left cavities being
principally affected. The three orders of carnem columnae were
much hypertrophied. Two large fleshy columns, as usual, occu-
pied the lateral margins of the contracted mitral orifice. They

186

DISEASES OF THE VALVES OF THE HEART.

were in close contact with the ventricular or under-surface of
the valves. This under-surface was strengthened by the chorda;
tendinea;, which were thrown much into relief. The aortic valves
were hypertrophied, and presented a convex appearance towards
the ventricle, as if they were distended, but showing a triangular
opening in the centre; each side of this triangle was nearly a
quarter of an inch in length; it exactly occupied the centre of
the area of the aorta. Adhesion had taken place between the
edges of the valves, and their margins were thickened and
rounded.

The left auricle presented some remarkable appearances. It
was much dilated and thickened, and the openings formed by the
pulmonary veins were singularly enlarged. They were oval, and
fully an inch in length and half-an-inch in breadth. The lining
membrane was opaque and greatly thickened. The valvular orifice
presented the appearance of a semilunar fissure: viewed from the
auricle, its convex margin was forward, and its concave backward.
This crescentic fissure was found completely closed by a coagulum
of the size of a filbert. This was probably the immediate cause
of death, closing the orifice like a bullet valvea.

The existence, in cases of contraction of the opening, of an iso-
lated and probably moveable coagulum in the auricle, capable of
causing death by a sudden occlusion of the orifice, has not, so far
as I know, been noticed by any author except Dr. Adams. It is
a most interesting and important fact. In another case recorded by
Dr. Adams the coagulum was rounded, and exhibited concentric
layers. Here the process of occlusion was probably more gradual,
as the coagulum itself exhibited on its surface a perfect cast or
mould of the contracted orificeb.

* The heart was exhibited by Dr. Adams to the Pathological Society on the 18th of
January, 1845. (See the Transactions, Dublin Medical Journal.)

b “ The cavities of the heart,” says Dr. Adams, in his observations on disease of the
mitral valves, “I have in general found filled with coagulated blood, which in some cases
I have seen assume the appearance of the polypiform concretions which so much at-
tracted the attention of the older pathologists. Most of these coagula had the appearance
of recent formations, but my friend, Mr. M'Dowell, last winter found in the left auricle of
a subject who died of the disease we are now considering, a ball as large as a pigeon’s
egg ; it was formed of the fibrine of the blood, was very firm in its consistence, and of a

187

dishase of the mitral AND AORTIC VAtVES.

Another important feature in this case is the dilated condition
of the pulmonary veins. These vessels were enlarged in every
direction, so as to be at least double their natural dimensions.
If the frequent occurrence of apoplectic effusions in the lungs ol
persons who have laboured under contraction of the mitral ori-
fice be considered, the state of the veins in the case now given
acquires an additional importance. For it seems not unlikely
that pulmonary apoplexy may be of two kinds, one produced by
increased action and over-loading of the arterial system of the
lungs, as when the disease arises from hypertrophy of the right
ventricle ; and the other from distention of the pulmonary veins,
when the passage of blood from the left auricle is obstructed ; in
the first case the masses are formed by the unarterialized blood , in
the second, by the blood after it has passed into the capillaries of
the pulmonary veins. Local collections of blood, probably caused
by over-distension of vessels rather than by rupture, take place,
having an analogy to those collections of the bile which we find
disseminated through the liver when the biliary duct is obstructed.
It may be a question whether the co-existence of an hypeitro-
phied right ventricle is necessary for the production of these apo-
plectic masses in cases of mitral obstruction. On this subject my
experience does not warrant any positive opinion, but I have
seen the apoplectic state of the lungs in a case where, at all
events, none of the usual signs or symptoms of hypertrophy of
the right ventricle were observed.

The following case presents an example of disease affecting
the mitral and aortic valves. It is the only one in which, guided
by the observations of Dr. Law, we ventured to make the diagnosis
of the double lesion.

figure perfectly spherical, except that there was an oblong depression on it, which cor-
responded accurately to the form of the edges of the fissure by which the left auricle and
ventricle communicated ; small fossre also, which must have been produced by the bony
spiculaj, were seen upon its surface ; from all which it was manifest it could not have
been of recent formation. We examined this curious specimen of polypiform concretion
too accurately to bo deceived upon these points, and this, and the heart in which it was
found, we have preserved.” — Cases of Disease of the Heart , $*c., hy Robert Adainsr
M. Z)., §-c. (Dublin Hospital Reports, vol. iv.)

This curious specimen is preserved in the Museum of the Carmichael School of Medi-
cine.

188

DISEASES OF THE VALVES OF THE HEART.

Case XXII. — Permanent Patency of the Aortic orifice, with Con-
traction and Ossifi cation of the Mitral valves ; Dilatation, with Hy-
pertrophy of all the cavities of the Heart; Double bellows mur-
mur at the base of the Heart, with a single murmur masking
both sounds towards the apex; Great enlargement of the right
aui'iculo-ventricular opening.

A man aged 35, of intemperate habits, was admitted into
the Meath Hospital in December, 1851. He had enjoyed good
health until about four months previously, when he experienced
a severe attack of dyspnoea, which came on suddenly, and for
the first time. This distress in breathing gradually increased ;
and about three week before admission he was attacked with
cough and severe pains in both shoulders ; his expectoration be-
came mixed with blood, and symptoms of oedema and ascites
showed themselves. On admission, the veins of the neck were tur-
gid, the lips livid, and the face bloated. We found the action of
the heart to be strong and irregular, with visible throbbing of
the arteries of the neck and upper extremities ; but the pulse at
the wrist wanted the usual volume observed in cases of insuffi-
ciency of the aortic valves.

We could distinguish four seats of valvular murmur.

1. A double bellows murmur at the base of the heart, propa-
gated into the aorta and subclavian arteries. The carotids did
not present murmur, but gave a hard and, as it were, hammering
pulsation.

2. A loud single murmur to the left of the nipple, evidently
systolic.

3. A distinct bruit de moulin at the junction of the second
and third right costal cartilages with the sternum.

4. A hoarse systolic murmur audible in the inter-scapular
region.

We also observed that the right lobe of the liver was enlarged.
Symptoms of progressive pneumonia of the right lung set in ;
under which he sank in less than a fortnight from the period of
his admission. For a few days before death he complained much
of the beating of the heart at the right side of the chest ; and the

DISEASE OF THE MITRAL AND AORTIC VALVES. 189

throbbing of the neck and in the radial artery almost wholly dis-
appeared.

On dissection, the right lung was found in a state of purulent
infiltration (third stage of Laennec). The left lung was healthy,
and the pericardium contained about eight ounces of clear serum.

Both ventricles were hypertrophied and dilated ; the right au-
ricle was considerably enlarged, and the opening into the ventri-
cle augmented to nearly double its usual dimensions. We found
the left auriculo-ventricular valves presenting the usual appear-
ance of ossific deposit in an early stage. They were thickened,
shrivelled, and incapable of closing: the aortic valves, cribri-
form, and with their edges covered with vegetations, permitted
free regurgitation.

After what has been said of the dangers of over-refinement in
diagnosis, it will not be supposed that in this particular combina-
tion of murmurs we may declare that both sets of valves are affected.
The opinion in this case was given as it were experimentally, and
it happened to prove correct ; thus corroborating the diagnosis
of the double lesion as given by Dr. Law. But we must still
hold that the double disease may exist without the presence of
such signs, and, conversely, that their existence may imply some
other form or combination of lesions. There is one point in the
case worthy of note, as being of greater value in the diagnosis of
the double lesions than even the character and seat of murmur,
and it is, that the pulse wanted the volume commonly seen in in-
adequacy of the aortic valves. It will probably be found that
if, with the double murmur under the sternum, and the visible
pulsation of arteries, the pulse is small and irregular, we may
suspect that there is mitral contraction as well as a permanently
patent state of the aortic valvesa.

The diagnosis of double valvular lesion in this case was founded
on the observations originally made by Dr. Law, that, in certain
cases of the contraction or insufficiency of the aortic valves, with
a contracted mitral orifice, he could distinguish two seats of mur-
mur: one, towards the apex, a single murmur; and the other,
which is double, loudest at the base of the heart, and propagated
into the great vessels. But it is not in every case of this combination

a The state of the left auricle and the pulmonary veins was not noted.

190

DISEASES OF THE VALVES OF THE HEART.

that wc can make this diagnosis, for the mitral valves may be so
altered as that no murmur whatever shall be produced during the
passage of blood through them ; and again the murmur from the
aortic opening may be so loud, and also so propagated downwards
into the ventricle, as to obscure the mitral murmur, even should
it exist.

If the question as to the practicability of the negative diag-
nosis, with reference to either orifice, be raised, it appears probable,
that where a mitral murmur is manifest, it will be easier to deter-
mine the absence of disease of the aortic valves than to declare
the integrity of the mitral valves in a case of aortic patency. The
experience of each succeeding day devoted to the study of dis-
eases of the heart will make us less and less confident in pro-
nouncing as to the absence of disease in any one orifice, although
no physical sign of such a lesion exist, if there be manifest disease
in another, or again, if there be symptoms of an organic affection
of the heart.

I cannot offer any statistical statement with reference to the
frequency of this combination, but we may with safety declare
that it is one of common occurrence. Forget holds that cases in
which the aortic valves alone are affected are less numerous than is
generally supposed, and are about as frequent as those of isolated
disease of the mitral opening; and again, that the simultaneous
affection of the two sets of valves is as frequently met with as
cases of the isolation of disease in either orifice11. This statement
is probably not far from the truth, if we consider the mere occur-
rence of anatomical lesion rather than the actual amount of dis-
ease. It is, however, probable, that if we discard cases of slight
alterations, insufficient to interfere with the action of the valves,
it will be found that there are more cases of isolation of disease
of the mitral than of the aortic orifice. Sucli at least is my pre-
sent impression, drawn not only from the results of dissection,
but from experience of cases, in which, without the signs of in-
sufficiency of the aortic valves, those of mitral disease have con-
tinued for many years.

The statistical investigations on which these views of Forget are founded were pub-
lished by him in his Etudes Cliniques more than six years ago. The number of cases
observed was 29, and the proportions were as follow : — Isolated aortic cases, 9 ; isolated
mitral cases, 10; combined cases, 10.— (Prdcis Thdorique et Pratique des Maladies du
Coeur, p. 157.)

DISEASE OF THE MITRAL VALVES, WITH CONTRACTION. 19 1

CONTRACTION OF THE MITRAL VALVES.

It has been shown, that if disease of the mitral valves be con-
sidered independently of functional or organic change in the
cavities, it appears so devoid of proper or distinctive symp-
toms as to be undiscoverable without the aid of physical exami-
nation. The period of this latent condition varies in different cases,
and when at last the so-called symptoms are produced, they indi-
cate combinations which may have preceded, but which in most
instances have followed on the valvular obstruction or insuffi-
ciency.

Among the contributions to our knowledge upon this subject
which have appeared since the time ofLaennec, the researches of
Dr. Adams are to be placed first in rank of importance, as they are
in time of publication. His memoir, which appeared in 1827, may
be held to mark a period midway between that of the discoverer
of auscultation and of the investigators of the present time. In
this memoir we find many observations which subsequent ob-
servers have without acknowledgment put forward as original.
Thus we find the law, as Forget terms it, of the dilatation atergo,
indicated by Dr. Adams, where he shows the effect of mitral ob-
struction in causing enlargement not only of the left auricle but
of the right ventricle. Again, the doctrines as to the pulsation in
the jugular vein3, synchronous with the ventricular systole, and
the natural insufficiency of the tricuspid valves, are here fully deve-
loped; and the special modifications of the form of the heart,
according to the predominance of disease in the auriculo-ventri-
cular, or the aortic valves, are accurately described. Lastly, the
mechanism and effects of the regurgitant diseases of the mitral valves
are detailed and exemplified ; and if aught were wanting to estab-
lish Dr. Adams’ character as a philosophical observer, it is the dig-
nified silence which he has maintained, while subsequent writers
have laid claims to the discoveries of facts which he long before
had announced. For there can be nothing more commendable than
to avoid controversy when the object is to establish the mere priority
of discovery, rather than the value and nature of a newly observed
fact. In a science like medicine, which advances or has advanced
less by the discovery of any great principle than by the accumu-

192 DISEASES OF THE VALVES OF THE HEART.

lation of isolated facts, it matters little to the right-thinking man
who, having discovered a new truth', finds it afterwards claimed
by another, if it be established and made available for good.

If we bear in mind that the so-called symptoms of narrowing
of the mitral valves are in reality those of a lesion of the cavities
of the heart, combined with valvular change, we can see that
the general group of symptoms of disease of the heart may be ex-
pected to arise in this affection, and by disease not only of the left
but the right cavities. The following analysis of symptoms will
place this matter in a clear point of view.

1. General Symptoms. — Palpitations; dyspnoea on exercise,
occurring independently of pulmonary disease ; cardiac pains.

2. Symptoms referrible to disease of the left side of the heart. —
Irregularity, rapidity, feebleness, and diminished volume of the
pulse ; syncope ; haemoptysis ; sudden death.

3. Symptoms referrible to disease of the right side.^-Ve nous
turgescence ; pulmonary congestion ; pulsation of the jugular
veins ; varying enlargement of the liver ; anasarca ; want of pro-
portion between the strength, and perhaps the rapidity of the
action of the heart and pulse.

It will not be supposed that any one of these symptoms be-
longs exclusively to the lesion under which it is classed. Thus
haemoptysis may occur either from increased action of the right
ventricle, or obstruction at the mitral orifice, causing dilata-
tion of the left auricle and pulmonary veins. Again, signs of
affection of the brain may be observed to depend on deficient
supply of arterial blood, as in syncope, or upon turgescence of the
venous system, as in the coma and asphyxia in disease of the
right side of the heart ; but still, this general statement of the
symptoms will help us to take a broader view of the nature and
effects of a valvular disease which was at first but an isolated af-
fection.

The symptoms of mitral obstruction are divisible into two
classes ; viz., those which result from mechanical impediment to
the flow of blood, and those which indicate irregularity in the ac-
tion of the heart. Among the former we may place, —

1. The evidences of congestion of the lungs, as shown by the
symptoms of cardiac asthma, bronchial disease, hajmoptysis, and
oedema of the lung.

CONTRACTION OF THK MITRAL ORIFICE.

193

2. Evidences of obstruction at the right side of the heart, with
its consequences, such as hepatic and cerebral congestion, general
dropsy, and venous turgescence.

The second class of symptoms, or those indicating disturb-
ance of the action of the heart, are,—

1. Irregularity and often rapidity of action, which may be
either constant, or excited by various disturbing causes.

2. Want of proportion between the force of the impulse of the
heart and that of the pulse in the arteries ; the latter being often
small and indistinct, while the former is strong and manifest.

3. Want of proportion between the rate of the manifest pulsa-
tions of the heart and of the pulse at the wrist; the former being
often apparently more rapid than the latter.

With reference to the want of proportion between the heart
and pulse, not only as to force but rapidity, Dr. Adams has the
following observations: —

“ First, when we recollect that the right ventricle is actively
enlarged, and at the same time pushed forwards towards the ster-
num by the dilatbd auricles above and behind it, and, moreover,
that these three cavities just mentioned have a resistance to over-
come at the left auriculo-ventricular aperture, we have no reason
to be surprised at the vigorous pulse of the heart, to which the
diminished left ventricle can contribute but little, as it is placed
so much behind its usual situation. Secondly, the pulse in the
arteries is small, weak, and irregular, and less frequent than that
of the heart, — because the pulse of the former is the indication of
the state of the left ventricle, which, as has been already men-
tioned, is reduced in size. And we can account for the irregu-
larity of the pulse in the arteries when we bring to mind that
the left ventricle derives from the auricle above it a very preca-
rious supply of blood, which is probably often inadequate to fill
its cavity. Under such circumstances, the left ventricle may con-
tract in unison with the right, but the stream it has to transmit
will not be sufficient to distend the arteries, or make the pulsation
sensible. At such a moment there is a total failure of the arterial
pulse, while that of the heart (caused by the action of the right
ventricle) is strong and vigorous ; hence the phenomenon charac-

.VOL. i.

194

DISEASES OF THE VALVES OF THE HEART.

teristic of this disease, — the occasional double pvdse of the heart for
the single pulse in the arteries.”

In corroboration of this view of the want of proportion in
rate between the pulsations of the heart and the radial artery,
the following case is given : —

“ A woman, who had for about a year laboured under the ordi-
nary symptoms of valvular disease, with running attacks of dropsy,
presented the following conditions: — The chest was well formed;
the action of the heart was rapid, strong, and irregular, while the
pulse at the wrist was weak and thready ; and although its beat
was for the most part synchronous with that of the heart, there were
often two, three, or even five pulsations of the heart at a moment;
then all pulsation was suspended in the arteries, and could not be
felt by the finger placed accurately over the radial artery. The
pulse counted here ranged at the rate of about 120 in the minute,
and the beats of the heart during the same time exceeded by 10,12,
or 15 that number. I have never seen the pulsations in the jugu-
lar veins more evident than in this case ; and I ascertained that
their beats corresponded accurately with every pulse of the heart ,
and even with those which were not felt in the arteries; moreover ,
when pressure teas made on the exterior jugular veins, two or three
inches above the clavicles , the veins became distended beneath this point
during their pulsations , even more than when the pressure was
omitted ”a.

The doctrine that it is by the influence of the blood, either in
its quality or quantity, that the ventricle is stimulated to contract,
is strengthened by this observation. Independent, however, of
this consideration, we may admit, that the feebleness and want of
volume of the pulse in such cases is not to be attributed, as some
might suppose, to a weakened state of the left ventricle, first be-
cause we have no anatomical evidence that such a condition is com-
monly attendant on mitral obstruction ; and next, because m cases
of manifest weakening of the heart, as in fatty degeneration, and
in die typhoid softening, where the action of the heart is regular,
though often so depressed as that the first soundis inaudible, nosuch

a Op. cit., p. 420. I have taken the liberty of giving the latter portion of this pas-
sage in Italics, in consequence of its groat importance.

CONTRACTION OF THE MITRAL ORIFICE.

195

phenomenon as the heart acting more rapidly than the pulse has
been observed.

This explanation of the character of the pulse in mitral disease
was given by Dr. Adams in 1827. In Dr. Hope’s work, of which
the first edition appeared in 1831, the author, speaking of disease of
the mitral valves, says, — “ The explanation of the pulses in ques-
tion I conceive to be as follows : — In the case of contraction of the
mitral orifice, the left ventricle, not being freely supplied with
blood, is not stimulated to contract at the natural intervals with
suitable energy and with equal degrees. In the case of regurgita-
tion, the ventricle, having lost the resistance of the mitral valves,
expends the force of its contraction in the retrograde as well as in
the forward direction, and also expels into the aorta a diminished
quantity of blood, whence the pulse is proportionably feeble and
small; further, as the regurgitation disturbs the regularity of the
supply to the ventricle, more or less of intermittence, irregularity,
and inequality are sooner or later the result.”

It is plain that, as regards the effects of the diminished supply
of blood to the left ventricle, the views of Hope and Adams are
the same, although the observations of the latter are not noticed
by Dr. Hope.

But even in the second part of the explanation, Dr. Adams
has priority of observation. In his comments on a case of con-
traction and patency of the mitral orifice, he observes that “ the
heart was of a peculiar form, owing to the greater capacity of the
right side than the left. The pulmonary artery was unusually
dilated; the aorta contracted; the left ventricle was diminished
in size ; the auricle a little dilated ; the mitral valves were not half
their ordinary depth, their borders were shrivelled and puckered
up, as if a thread were drawn through them, and contained some
spicukeof bone, — they were manifestly incompetent todomorethan
half guard the aperture of communication between the auricle and
ventricle. This aperture was contracted, but was still large enough
to admit easily the extremity of the index finger to the first joint,
and it must have permitted the blood to pass without much diffi-
culty from the auricle into the ventricle. In consequence of the
shortening of the valve, it imperfectly covered the auriculo- ven-
tricular opening, and too readily allowed of a reflux of blood into

o 2

196

DISEASES OF THE VALVES AT THE HEART.

the left auricle during the contraction of the ventricle; hence
the effect of the heart, instead of being, as it is in the natural state,
expended in propelling onwards the blood through the aorta, was
partly lost, because of the imperfect state of the valve admitting
a regurgitation of some of the blood which was destined to pass
into the aorta; the heart was therefore obliged to reiterate its
beats, to compensate by its quickness for that small quantity of
blood it was capable of forwarding at one contraction through the
aorta”a.

It must be admitted, that the real or apparent difference of
rate between the impulse of the heart and that of the artery, as ob-
served at the wrist, has not yet received sufficient investigation.
As one of the symptoms of disease of the mitral valves, it is of great
value ; and a difference of not less than fifteen beats between the
rate of the heart and pulse has been observed. Even a greater
discrepancy may occur.

I have lately observed a case of mitral obstruction in which
two distinct conditions of the heart’s action are to be seen. In
the one the action is comparatively tranquil and regular, and the
mitral murmur is evident. In the other, the heart acts with great
rapidity and irregularity, and the murmur becomes imperceptible
or nearly so. In the latter condition there is a marked difference of
rate between the pulse at the wrist and at the heart, so much so that,
taking all the doubtful pulsations of the radial artery into account,
there remains a difference of between 30 and 40 pulsations in fa-
vour of the heart. In making this observation every precaution
to avoid error was taken, and I found that the best method of as-

* “ In this organic change of the valvular apparatus at the left side of the heart,”
observes Dr. Adams, “ by which a return of blood from the brain and lungs was impeded,
we find the source of the quickness of the pulse, the vertigo, the dyspnoea, and the sud •
den termination of these cases.” — Dub. Hasp. Reports , vol. iv. p. 422. The author gives
two cases of contraction of the mitral opening, in both of which permanent rapidity of
pulse was observed; and he remarks, that “ in both he found the mitral valves and auri-
culo- ventricular opening in a state nearly similar, although the effects of this organic
change were so dissimilar that, one patient having died of apoplexy, and the other in an
epileptic fit, it would not be easy to assign any reason for these differences, nor to explain
why the cases terminated so speedily. They are useful, however, in showing, that even
in the first stage of this disease, life is very insecure ; and the dissections present us with
•what we have not often an opportunity of seeing, namely, the change of the mitral valves
which takes place when this disease is in what may be termed its first stage.”— Op. ctt.

CONTRACTION OF THE MITRAL ORIFICE. 197

celtaining the actual number of the heart’s pulsations was by ap-
plying the stethoscope to the lower portion of the sternum, where
the contractions of the right ventricle give a sound much more
distinct than those of the left.

If we now compare the action of the heart with that of the
pulse at the wrist, confining our observations to the characters of
strength, rapidity, and regularity, we may admit three groups of
cases.

In the first, there is little, if any, disturbance of heart or pulse.
The relation as to time between the stroke of the heart and of
the pulse corresponds to that in a state of health ; there may be
no irregularity or intermission, and the force of the pulse appear
unaffected. All this time a distinct mitral murmur is to be re-
cognised; yet, with the exception of this sign, no evidence exists
of disease of the heart.

In the second set of cases we observe, not only a want of pro-
portion between the strength of the beats of the heart and pulse, —
the former being much stronger than the latter, — but also a differ-
ence in the rate of pulsations, those of the heart exceeding those
of the pulse by a number which may vary from 15 to 25 or 30.
In this case the want of volume in the pulse is owing to the con-
traction of the auriculo-ventricular opening, causing a diminished
supply of blood at each systole of the heart, and the organ has
probably the globular shape produced by the enlargement of one
ventricle, while the other remains unaffected, or even diminished
in size.

Finally, of the third group we have a type in the case by
Dr. Fleming, presently to be given, where the diminished volume
of the pulse appeared to arise from free regurgitation into the
auricle, while the left ventricle was in the state of hypertrophy
with dilatation. It is still to be determined whether in such a
case the want of proportion between the heart and the pulse as to
the number of beats is to be met with.

The existence of a permanently rapid pulse, with or without
irregularity, and occurring in an apyrexial state of the system,
should lead us to infer that some disease of the heart was pre-
sent. The chances that such a condition existed would be greatly
increased if irregularity coincided with rapidity of pulse: and

198

DISEASES OF THE VALVES OF THE HEART.

these probabilities would be converted into almost a certainty by
the discovery of murmur with either sound of the heart, a murmur
which was constantly present, or only evident when the heart’s
action was comparatively slow and tranquil. But what opinion
should he given in the case of a permanently rapid pidse without
pyrexia, without valvular murmur, or any evidence of obstruction
in the pulmonary or hepatic systems? Such a case, indeed, is rare,
but it may occur, and the question will arise, whether the absence
of valvular murmur implies absence of valvular disease ; or whe-
ther the case is one of that class in which a murmur would
he discoverable if the action of the heart was slow. On this ques-
tion, I have only to remark, that I have never seen the masking
of valvular murmur by a rapid action of the heart, in which there
was both the want of valvular murmur and the absence of signs
of pulmonary and venous congestion. So that the conclusion
appears justifiable, that a merely rapid pulse, if it be isochronous
with the heart, does not necessarily imply that the individual lias
cardiac disease, and more especially if murmur has never been
present, and if the lungs and hepatic system have exhibited no
sign of disease.

Pulsation of the Jugular Veins. — This striking symptom, held
by Lancisi to indicate a dilated state of the right ventricle, has re-
ceived an additional value through the researches of Dr. Adams, who
has shown that it often occurs in mitral obstruction, so commonly
a cause of dilatation of the right cavities. This pulsation, though
not necessarily present in mitral valve disease, is found to be syn-
chronous with the contraction of the ventricle, an observation of
great importance, not only with reference to the signs of cardiac
disease, but as bearing on the entire theory of the heart’s action
in a state of healtha.

a The pulsation of the jugular veins, the “venous pulse” of authors, to which Tesla has
given the name of the arteriosity of veins (Malattie del Cuore, vol. iii. cap. xvii.), was no-
ticed long before tiie time of Lancisi, although the doctrine of its connexion with disease of
the heart belongs to the latter observer. It was described by Galen as occurring in a case of
severe cephalalgia ( vide Commentaries on Hippocrates, as quoted by Testa, vol. iii., cap.
xvii.). Testa quotes from Zuliani, with reference to a case in which the pulsations of the
veins of the arm resembled those of the artery : “ Chirurgus venam sccaturus confunde-
retur mclueretque The same author quotes from Uccelli (Observ. iii.) as to a case
observed in the hospital of Brescia, in which there was manifest pulsation of the lateral

CONTRACTION OF THE MITRAL ORIFICE.

199

The pulsation of the jugular veins, when occurring in disease
of the mitral valves, results from the regurgitation of blood from
the right ventricle into the auricle, by which the current de-
scending from the jugular veins Is repelled into those vessels dur-
in<r the systole of the ventricle. Dr. Adams has observed, that,
the pulsation in the jugular veins is synchronous even with
those pulsations of the heart which are not perceptible in the
arteries. The following passage from his memoir is impor-
tant.

“ Mr. Hunter, in his Treatise on the Blood, has remarked that
the valves of the right side Of the heart did not so completely close

portions of the neck. The right auricle was natural, while the right ventricle “ unice di-
latatus aliquantulum apparebat.” It is remarkable that Testa, in alluding to these cases
and to others, where the auricle, to use the words of Morgagni, “proliibente crusta in-
terna sive cartilaginea , sive ossea, ipsaque hujus, autparietum reliquorum duritie, contra -
here se non poterat, sed rigida, et injlexilis in perpetua dilatatione permanehat,” (Epist.
Anat. xviii., Art. xii.), leads us to infer that the pulsation of the vein must be synchro-
nous with the ventricular contraction. In these cases he observes, that the reflux of blood
by the superior cava is solely owing to this, that the right ventricle receives a greater quan-
tity than can be admitted into the pulmonary artery, from which he says, in consequence
of some defect in the anriculo-ventricular valves, it happens that the same contraction of
the ventricle which transmits the blood to the lung, returns at the same time some por-
tion of it to the auricle, from which, but a moment before, it had passed ; hence the blood
returning a second tune into the jugulars, and meeting there the current flowing towards
the heart, causes their sudden distention. (Op. cit. vol. iii. p. 379.) The case of venous
pulsation recorded by M. Ilombert is well worthy of study. The patient, a lady of about
thirty-five years of age, had suffered for upwards of fifteen years from attacks of asthma,
attended with violent palpitation and pains in the thorax. When the palpitations were
most severe, distinct pulsations could be perceived in the veins of the arm and the neck.
The frequency of these pulsations was slightly different from that of the arteries, but cor-
responded exactly with the violent impulses of the heart itself. When the paroxysm was
over, the pulsation of the veins ceased. On dissection the heart was found of twice its
natural size, and as flabby as a bag of soft leather. The cavities were greatly distended,
and the parietes of the heart very much thinned ; in both the pulmonary artery and the
aorta, polypi were found, whose roots were attached to the internal surface of the respective
ventricles. The coagulum in the aorta having been removed, was found not less than two
feet in length. The clot, for a length of six inches, was firm, red, and had the ap-
pearance of flesh. Hombert attributed the pulsation to reflux into the veins on each con-
traction of the heart, — “ L'on pourroit comparer ce repoussement sumaturcl du sang
dans les veines au gonflement et an repoussement des eau.v coulantes des Iiivieres par les
hautes marees'' — and he attributes the distention of the heart to the obstruction of the
arteries by the coagula. (Histoire de T Academic Royalc des Sciences, AnnC-e mdcciv.
p. 161.)

200

DISEASES OF THE VALVES OF THE HEART.

the arterial and auricular openings as those of the left; but this
circumstance, in my opinion, has not been sufficiently noticed,
nor the influence that such a structure may have on the circula-
tion in its natural or morbid state considered. I look upon this
difference in the valves of the right and left side of the heart to
be a natural provision to allow of a partial reflux into the right
auricle, on those occasions when from any cause the passage of
the blood through the arterial opening is retarded. Such a pro-
vision was absolutely necessary in the right or pulmonary ventri-
cle, as various natural causes must momentarily retard the passage
of blood through the lungs. Let us suppose the right ventricle
to contract vigorously at such a crisis. Some part of the valvular
apparatus (which is not very strong at this side) or the ventricle
itself might give way, were there not some other course for the
blood than through the pulmonary artery : in the natural state of
the heart it is probable that there is constantly some little reflux
into the right auricle during the contraction of its corresponding
ventricle, as the valves readily admit it, but the great swelling of
the jugular veins is only seen when extraordinary efforts are made,
or when, from any enlargement of the right side of the heart, it is
capable of containing a larger quantity of blood than it can rea-
dily transmit through the lungs, or the left receive; on these oc-
casions it is that the pulsations in the jugular veins become evi-
dent; they are synchronous with the action of the heart, and can
more readily take place when the right ventricle has been preter-
naturally dilated, as it is not likely that the valve will increase in
size and breadth in proportion as the auriculo-ventricular aperture
enlarges.”

It is still to be determined whether the form of jugular pul-
sation we have now considered is only to be met with in contrac-
tion of the mitral valves ; so little, however, is known of the diag-
nosis of a permanently patent, yet dilated mitral opening, that
nothing definite can be stated on the subject. There appears,
however, no reason why, if the pulmonary circulation suffered
from such a condition, we should not observe a jugular pulsation
in this disease as well as in that of narrowing of the orifice®.

» The important memoirs of Mr. Thomas Wilkinson King, on the safety-valve func-
tion of the right ventricle of the human heart (Guy s Hospital Reports, Nos. iv. and xii.),

CONTRACTION OF TUB MITRAL ORIFICE.

201

Three morbid phenomena are to be observed in the jugular veins
in organic diseases of the heart, namely: — 1. Dilatation without
pulsation ; 2. An undulatory action which may be looked on as
an approacli to pulsation ; and 3. A well-marked reflux pulse,
perceptible to the touch as well as to the eye, and in a few cases
attended by a faint murmur, but yet one which corresponds to each
beat in the vein. The simple dilatation may be seen independent
of any irregularity of form ; but in some cases the vein exhibits a
knotted appearance, giving the idea of the existence of septa,
which cause a narrowing of the caliber of the vessel at various
points.

Of these conditions, the pulsation of the vein is the most im-
portant, and was held by Lancisi to indicate an enlarged state of
the right cavities of the heart. It is essentially a proof of obstruc-
tion to the pulmonary circulation and an overloaded state of the

are worthy of the most careful study by every one interested in this part of the subject.
To Dr. Adams, however, is due the credit, not only of developing the doctrine of the safety-
valve function of the tricuspid valves, considered physiologically, but of showing the en-
tire bearings of the subject in reference to disease ; and we cannot assent to the statement
of Mr. King, that Dr. Adams does not assign any cause for the regurgitation, unless it be
dilatation of the auriculo- ventricular aperture. ( Vide note to his first memoir, p. 126 )
An examination of what Dr. Adams has said, not only rvith reference to the normal state
of the tricuspid valves, but also when he compares them with the mitral valves, will esta-
blish what has been now advanced. We have above quoted his observations on the insuffi-
ciency of the right valves, considered a3 a natural provision. Farther on he says: —

“ Before I conclude these observations on the healthy and deranged action of the auri-
culo-ventricular valves, I may remark, that the mitral valve so perfectly closes the aper-
ture of communication between the left auricle and ventricle, that in the natural state no
reflux whatever is admitted. This (the reflux), so useful at the right side of the heart, would
have been not only useless but injurious at the left side of the organ, as we find the general
arterial system at all times equally ready to receive the blood during the systole of the
left ventricle; and if the mitral valve did not perfectly close the left auriculo-ventricular
aperture, a great deal of the force of the aortic ventricle would be wasted, whereby it
would be incapable of moving the mass of blood which was destined to fill the arterial
system. Pathologists, in looking to the different nature of the lining membrane at the
two sides of the heart, as a means of explaining the greater liability of the left side to
disease, have, perhaps, too much overlooked this circumstance, that while, from the un-
yielding nature of the mitral valve, all reflux into the auricle is prevented, from this very
cause, which renders it effective in the circulation, is it exposed to more frequent injury
from which organic disease may arise, and the ventricle to which it belongs become moro
liable to be ruptured by its own efforts.” — Dublin Hospital Reports , vol. iv page 439.

202

DISEASES OF THE VALVES OF THE HEART.

right ventricle. Hence we may infer, that it should occur in the
following cases: —

1. Obstruction of the pulmonary artery or its valves.

2. Dilatation of the right cavities of the heart.

3. Obstruction of the left auriculo-ventricular opening.

It is not fully determined whether, in the last case, the sign
in question indicates a permanent organic change of the right auri-
cle and ventricle, such as dilatation with or without hypertrophy,
or whether it may not arise from temporary distention of these
cavities. In the case recorded by Ilombert, it was remarked, that
the pulsations in the jugular and brachial veins were most evident
during the paroxysm of cardiac asthma.

Although the facts brought forward by Mr. King seem to es-
tablish that, in certain cases a pulsation of the veins, independent
of organic disease of the heart, and really propagated from the
arteries through the capillary circulation, may be met with, yet,
on the other hand, it appears certain, that the venous pulse is
more frequently the result of regurgitation from the right ventri-
cle. We owe to Dr. Benson one of the best recorded cases of ve-
nous pulsation, in which the veins on the back of the hand and
the superficial veins of both upper extremities showed a distinct
pulsation. The veins were prominent, and by some the pulsa-
tions could not only be seen but felt. These pulsations were a
little later than those of the radial artery. In consequence of the
increased action of the carotids it was difficult to say whether the
jugular veins were pulsating. During each act of respiration they
became distended, and then collapsed; whilst a confused, tremu-
lous pulse incessantly agitated them.

In consequence of the rapid supervention of coma, no accu-
rate history of this case could be obtained ; but physical examina-
tion showed that the heart was hypertrophied, and that there ex-
isted some important valvular disease.

A small bleeding having been made from the arm, Dr. Benson
was surprised to find that the blood did not come per saltum, al-
though pulsation was observed in some of the veins below the
bandage. The pulsation had ceased and remained absent for the
following day ; it returned, however, and remained for the next

CONTRACTION OF THE MITRAL ORIFICE.'

203

three days, and the patient sank. A small bleeding was per-
formed on the day before death, when it was found that the blood
flowed per saltum; from this time no motion in the veins could

be seen.

« The heart,” says Dr. Benson, “was at least twice the usual
■ size. The auricular appendages, especially the left, were remark-
ably large. The right auricle was dilated and a little hypertro-
: phied. At the posterior margin of the foramen ovale a particle ol
' osseous matter was observed. The right auriculo-ventricular open-
ing was very large and gaping. The right ventricle was dilated
and hypertrophied. Its cavity was twice as large, and its walls
i twice as thick as usual. The floating margins of the tricuspid
valves were thickened and studded with small cartilaginous no-
dules. The pulmonary artery was healthy, but its valves appeared
somewhat thickened, and their corpora sesamoidea much deve-
loped. The left auricle was enlarged, its walls thickened, and the
lining membrane peculiarly white and opaque. The opening from
it into the ventricle was too small to admit the finger; it was an
irregular slit-like opening, surrounded with cartilaginous and os-
seous deposits. The left ventricle was dilated, its walls a little
thickened, but softer and paler than those of the right. The mi-
tral valves contained calcareous and cartilaginous deposits. The
aortic valves were greatly thickened, and filled with osseous mat-
ter. The aorta, too, had osseous deposits. The superior vena cava,
the innominatEe, jugular, and subclavian veins, were slit up and
carefully examined: nothing peculiar was observed in them ; their
coats were of the usual appearance, and their valves in the ordi-
nary situations. The abdominal viscera were healthy. The brain
was pale and bloodless: it showed no sign of congestion, nor of
any disease except that the ventricles contained about lialf-an-
ounce of clear serum”a.

We must agree with Dr. Benson in his opinion that the pul-
sation in this case was regurgitant, and to be attributed to the con-
dition of the right ventricle ; and the case strongly corroborates
the views of Dr. Adams as to the connexion between venous pul-

1 A case of pulsation in the veins of the upper extremities, by Charles Benson, M. D.
Bublin Journal of Medical Science, vol viii. First Series, 1836.

204

DISEASES OF THE VALVES OF THE HEART.

sation and the contraction of the mitral orifice, the remote cause
of tlie disease in the right cavities of the heart.

But the occurrence of a venous pulse does not necessarily
imply the existence of a chronic and incurable disease. I have
noticed well-marked jugular pulsation in a case of acute pericardi-
tis. The patient recovered, and there was no evidence of any or-
ganic disease prior to the inflammatory attack. In this case it is
possible that the right ventricle was weakened and temporarily
dilated, so that the tricuspid valves, naturally insufficient, were
rendered still more inadequate.

In conclusion, it is to he observed that among the causes of
cardiac asthma, contraction of the mitral opening is to be enu-
merated. It is not improbable, also, that a dilated orifice, with
inadequate valves, may produce the same .set of symptoms. We
have, in various works, good descriptions of a paroxysm of car-
diac asthma; but I do not know of any recorded observation of I
physical signs occurring in the paroxysm beyond those which
relate to the excited and irregular action of the heart. The case
I shall now detail will furnish some addition to our knowledge on
this subject.

A girl of about eleven years of age, of delicate habit, has from
a very early period of her life suffered from attacks of extraor-
dinary dyspnoea and orthopnoea, in the intervals between which
her health seems to have been good. She is of a delicate make
and nervous habit, but is able to take active exercise; and no
appearance of disease of the heart is shown by her ordinary mode
of breathing or the expression of the countenance. There is,
however, a permanent and slightly rough systolic murmur in the
heart, loudest near to the left mamma.

In this case the paroxysm is liable to be excited by indigestion,
by fatigue, or cold. I have had many opportunities of seeing this
child in the intervals of her attacks ; and on a late occasion I was
called to see her in a fearful seizure of her disease. The pulse was
small, unequal, and rapid to the last degree; and the respirations
more accelerated than in any case I had ever before witnessed.
There was constant cough, with wheezing, and an expression of
dreadful anxiety. When I saw her she had been twelve hours ill,
and I found that the left side of the chest was absolutely dull, ex-

ENLARGEMENT OF THE MITRAL ORIFICE,

205

cept in the postero-inferior portion. It was as dull as if the lung
had been compressed by a copious effusion. The heart’s action was
excited, and so irregular that to analyze the sounds was impossible.

. Considering that this child had not been a day ill, and also that the
• signs of dislocation of the heart were wanting, I felt great difficulty
i in determining from what cause this dulness proceeded. Treat-
i ment calculated to relieve the digestive system was adopted, and
i some anodyne and antispasmodic medicine given. These mea-

■ sures were followed by a considerable diminution of the excite-
1 ment of the heart; the clavicle now became clear on percus-

■ sion. During the next twenty-four hours the upper portion of
I the sternal region recovered its sound, and on the fourth day the
, dulness had completely subsided, and the chest had its natural

: sound, with distinctrespiratory murmur. These observations I made
with the greatest care, and on a careful consideration of all the cir-
cumstances, I can come to no other conclusion but that the dul-
ness was produced by a sudden and extraordinary distention of
the left auricle, so great as to displace the lung. Her recovery from
this attack was much slower than usual, and several weeks elapsed
before the heart was restored to its ordinary action. The parox-
ysm was not attended with cyanosis.

If we reflect on the causes which ordinarily produce complete
dulness of the upper portion of the chest, we cannot find any
which would explain the signs in this case. If it be recollected
that this complete dulness was suddenly produced, probably within
the course of a few hours ; that there were no preceding symptoms
or signs of consolidation from any cause ; that the signs of pleural
effusion were wanting, inasmuch as there was no displacement of
the heart; that the postero-inferior portion of the side was clear;
that the sonoriety of the chest was restored, although no anti-
phlogistic treatment was used ;and finally, that no crepitus of resolu-
tion, or any friction sounds, attended the disappearance of dulness ;
— we cannot but believe that it was really caused by a temporary
distention of the heart; and in all probability, reasoning from the
symptoms then existing, and the ordinary state of the patient, that
the left auricle was the seat of a vast accumulation of blood.

20G

DISEASES OF THE VALVES OF THE HEART.

DISEASE OF THE MITRAL VALVES WITHOUT CONTRACTION.

The division of cases of mitral valve disease into the regurgi-
tant and non-regurgitant forms cannot be maintained ; for the ef-
fect of organic change in the valves must be, in most instances, to
produce regurgitation to a greater or less degree. The following
division appears more justifiable: —

1. Contraction of the orifice.

2. The diameter of the orifice remaining unchanged.

3. The orifice dilated.

Our knowledge as to the special or differential diagnosis of
the two latter varieties is still limited ; and little more, can be
said than that, as compared with the first or ordinary case of contrac-
tion of the mitral orifice, they often want the symptoms of mecha-
nical obstruction, or at least that these are more slowly developed ;
and again, that when the orifice is dilated, we may have symp-
toms analogous to those of a weakened heart.

The following case occurred under the care of Dr. Fleming,
to whose kindness I am indebted not only for the report, but for
an opportunity of seeing the patient.

Case XXIII. — Sudden development of symptoms of organic Dis-
ease of the Heart ; Repetition of Pseudo -apoplectic attacks, at-
tended by ephemeral Hemiplegia and Jaundice; Dilatation of
the left ventricle and auricle; Great enlargement of the Mitral
orifice.

A gentleman, aged forty-four years, had enjoyed excellent
health up to the period of the first attack of cardiac distress,
which was sudden and unexpected. His habits were temperate
but sedentary, and, from being confined to his desk during six
days in the week, he could only take exercise on the Sundays,
when he made walking excursions to the country. On one of
these occasions he was attacked with dyspnoea, palpitation, and
pnecordial oppression. lie was soon afterwards seen by Dr. Flem-
ing, who found the pulse weak, small, and irregular, intermit-
ting, while the impulse of the heart was strong and much ex-

ENLARGEMENT OF THE MITRAL ORIFICE.

207

tended. A loud bellows murmur was found attending the second
sound of the heart.

The attacks of cardiac distress became frequent, and were
produced by bodily, or even mental exertion. A fremitus was found
to attend the murmur, which latter was very distinct in the inter-
scapular region, and at one point indeed louder than in the front
of the chest.

But the most important feature in this case was the frequent
occurrence of marked cerebral symptoms, very similar to those
observed in cases of fatty degeneration of the heart. These attacks
generally came on at night, or during sleep, the symptoms being
that the respiration would become suddenly stertorous, with some
convulsion of the face, when the patient would awake, perfectly
paralyzed at the left side. Jaundice also attended these attacks;
and it was most remarkable that both the hemiplegia and jaun-
dice would subside in a very short time. The full power of
the muscles would return within a few hours after the attack,
and on the following day scarcely a trace of jaundice could be
seen.

It 'was found that these attacks were only to be treated by the
use of stimulants. During one of them — owing to a different
course having been adopted in the absence of Dr. Fleming — the
patient was brought into the most extreme state of collapse. The
stimulants had been withheld, and the head blistered ; but, even
under these circumstances, so decided was the effect of stimulants,
that the patient, who in the morning was completely hemiplegic,
was within six hours perfectly restored to the use of his limbs.
This treatment was adopted in all the subsequent attacks, and
consisted in the use of wine and brandy, together with the appli-
cation of sinapisms to the region of the heart. The patient could
not bear the slightest reduction, and showed a remarkable sus-
ceptibility to the action of opium.

The heart was found to be much enlarged, owing principally
to a great increase in size of the left ventricle ; all the cavities, and
also the aorta, were fflled with blood. The general form of the heart
was remarkable ; it was globular, the apex appeared wanting, and
the left ventricle at its margin represented the segment of a circle.
The right ventricle was very small, having not more than a third

208

DISEASES OF THE VALVES OF THE HEART.

of the capacity of the left, the parietes of which were thickened,
though not to any very great degree. The aortic valves were
perfect. The mitral orifice was much enlarged. The circular
cartilaginous ring was fully the diameter of a crown-piece; so
that the valves, which were thickened, were quite incompetent to
close it. The foramen ovale remained open, although by a very
small orifice, which was oblique and valvular towards the left
auricle.

In this case the cerebral symptoms were, doubtless, of the same
nature as those which occur when the left ventricle is the seat of
fatty degeneration ; and future observations must determine how
far the open and dilated condition of the mitral orifice may have
tended to produce the effect in question, by diminishing the arte-
rial supply at each systole of the heart. Indeed, if we exclude the
stethoscopic signs, it may be said that, had the impulse of the
heart in this case been feeble, all the symptoms of fatty heart
would have been present in an extreme degree.

It has been thought that the presence or absence of paralysis
would serve to distinguish the true cerebral apoplexy from that
false or pseudo-apoplexy which occurs in cases of deficient supply.
It is true that, in most cases of fatty hearts, the cerebral attacks
have not been followed by paralysis ; yet, in a few, paralysis has
been observed; and in the case now given this condition at-
tended every attack, subsiding, however, with great rapidity;
none of the indications of chronic disease of the brain occurred
in this case.

The appearance of jaundice with each of the attacks, which,
like the hemiplegia, was ephemeral, is to be noted. Jaundice, as
attendant on contraction of the mitral valve, has been described,
but I do not know any instance of the repetition of a jaundiced
state, such as was observed in this case.

In connexion, however, with this subject, the following ob-
servation has some importance : A lady, aged about forty, of a
spare habit, complained of an itching of the skin, which was often
so severe as to deprive her of sleep: soon- afterwards her skin as-
sumed a semi-jaundiced tint, and she sought for medical advice.
The pulse was permanently rapid, though small, and yet there
were no symptoms of fever. The action of the heart was excited,

ENLARGEMENT OF THE MITRAL ORIFICE.

209

tmd the arteries of the neck were observed to throb with force.
Soon afterwards the thyroid gland became enlarged to about the
size of a hen’s egg.

The jaundice and itching of the skin continuing, the patient
was put under treatment for an affection of the liver, but no im-
pression was made on the symptoms. It was after this period she
consulted me. But little change had occurred in the symptoms.

The pulse was rapid and small ; and though the swelling of the
thyroid had declined to a great degree, more or less throbbing of
the carotids continued ; yet the pulse had none of the characters
observed in permanent patency of the aortic valves. A loud bel-
lows murmur attended the first sound, most distinct between the
nipple and lower portion of the sternum. No tumour of the liver
could be discovered, but the semi-jaundiced condition, varying
in amount from day to day, remained, notwithstanding a de-
cided mercurial treatment. The alvine evacuations were always
clay- coloured, but the urine remained of its natural appearance;
a combination of circumstances which I never before witnessed,
and which has now continued for several months.

The history of jaundice, and of affections of the liver, in con-
nexion with disease of the heart, has yet to be written. That the
jaundice in this case was consequent on organic disease of the heart
there can be little doubt ; and in this example, as well as in that
by Dr. Fleming, it was present under circumstances of great
peculiarity.

Before concluding these observations on enlargement of the
mitral opening, we should note that, in Dr. Fleming’s case, the
left ventricle was found to be dilated, a condition very different
from that observed in simple contraction of the orifice, so that
inadequacy of the valves maybe followed by dilatation of the ven- *
tricle, no matter whether the mitral or aortic orifice be the seat
of the lesion. In the case of the mitral valves, with an actually
enlarged opening, the ventricle and auricle may be held to form
one bilocular cavity, both portions of which have a mutual re-ac-
tion. The auricle having become distended, and probably hyper-
trophied, by regurgitation from the ventricle, sends an increased
quantity of blood into that cavity, which latter has to expend its
force not only in the direction of the aorta, but also in that of the

VOL. i.

210

DISEASES OF THE VALVES OF THE HEART.

auricle ; thus it becomes not only dilated but hypertrophied ; yet
as the quantity of blood propelled into the aorta must be reduced
in proportion to the size not only of the auricle, but also to that of
its orifice, we have produced those effects which result from a
weakened ventricle, even when no valvular lesion exists, as in
fatty degeneration of the left ventriclea.

A comparison between the symptoms and anatomical results
of the contracted and dilated conditions of the left auriculo-ven-
tricular opening is still a desideratum. It may be suggested
whether, in those cases in which a loud mitral murmur con-
tinues for many years without apparent injury to health, the
condition of parts is at all events not a contraction of the orifice ;
it may be that it is dilated, or that its natural diameter is little, if
at all, altered. This much is certain, that in such cases the indica-
tions of pulmonary congestion, and of hypertrophy and dilatation,
are for along time absent, and the course which should be adopted
is to preserve the general health ; and while we take measures to
avoid undue excitement of the heart, we must be especially careful
not to depress its energy by an undue amount of antiphlogistic
treatment. In fact, the principles laid down by Dr. Corrigan for
the treatment of cases of permanently patent aortic valves are
applicable in every respect to the condition which we have now
specified.

Although in a large proportion of cases of disease of the mi-
tral orifice there is regurgitation, even with a contracted opening,
yet we must admit a class in which this regurgitation becomes
an important condition, causing certain anatomical changes in
the cavities, and producing manifest symptoms. In such cases
the orifice remains of its natural dimensions, or becomes actually
dilated. We do not know any physical signs by which these
conditions can be distinguished from ordinary mitral disease, for
the murmur in cases of this lesion is probably regurgitant. But
in some examples of well-marked mitral murmur we find that
it is not perceived in the interscapular region, while in others

“ Dilatation and hypertrophy of the left ventricle are noticed by Dr. Walshe as atten-
dant on regurgitant disease of the mitral orifice. Among the causes of insufiiciency of
the valves, the enlargement of the orifice, without coeval growth of the valves, is consi-
dered by him to be of very rare occurrence. (Op. cit. p. 222.)

DISEASE OF THE AORTIC VALVES..

211

it is distinctly heard along the spine, sometimes, indeed, louder
in this situation than in the front of the chest. In such cases the
orifice is probably but little contracted, or, it may be, actually
dilated. We cannot, however, take this interscapular murmur
as diagnostic of free regurgitation, inasmuch as it may occur in a
contracted state of the orifice. An example of this has already
been given1 11.

The loud systolic murmur heard along the dorsal region of the
spine is, in most cases, indicative of very chronic disease. I once
observed it to supervene in a case of endo-pericarditis, and to be-
come permanent, although the ordinary signs of valvular disease
had subsided. I have suggested that, in many of those cases
where a mitral murmur continues for years without disturbance
of the general health, the condition of the valve is not one of con-
traction. In such cases the interscapular murmur may often be
found. Fremitus, too, appears more frequently associated with
the murmur in these cases than in those of ordinary contraction;
and when the dilatation is extreme, as in the instance of enlarge-
ment of all the orifices already given, and also in the example re-
corded by Dr. Fleming, it may become a prominent sign.

DISEASE OF THE AORTIC VALVES.

Comparing the diseases of the aortic with those of the auri-
culo-ventricular and pulmonary valves, we do not find that they
have any special anatomical character. And in a mechanical
point of view the effects of disease in this situation are the same
as in the others. Thus, inadequacy of the valves is the most com-
mon result, existing with or without a contracted state of the
orifice. ♦

We have already pointed out three cases of the disease of the
aortic opening in which, with great probability of accuracy, we
may make a special diagnosis; these were as follows: —

1. Permanent patency of the valves, in which the diameter of
the orifice may be increased or diminished, or remain in its na-
tural condition.

1 See page 188.

p 2

212

DISEASES OF THE VALVES OF THE HEART.

2. An extreme amount of ossific growth surrounding the ori- .
lice and stretching irregularly into the ventricle : here the valves
are often destroyed.

3. Earthy or atheromatous deposit on the ventricular face of
the valves, which latter, however, are still competent to close the
orifice. This condition is often seen in connexion with fatty de-
generation of the left ventricle.

It will be unnecessary to enter into detailed descriptions of
other pathological conditions of the valves, such as their atrophy,
producing a cribriform state, or those examples of dilatation of the
orifice which result from enlargement either of the ventricle or of
the aorta.

The most important, because the most frequent, of all these
lesions, is that in which, from regurgitation of blood, such im-
portant consequences follow, and such characteristic signs are pro-
duced*1.

At the commencement of this chapter it will be recollected
that the diagnosis of this disease, founded on the observations of
Dr. Corrigan, was given in outline. The following extracts
from the original memoir of that accurate and distinguished ob-
server being studied, we shall be in a position to take a general
view of this disease of the heart.

After alluding to the obscurity of the symptoms, Dr. Corrigan
observes, that what is deficient in the general symptoms is amply
supplied by the certainty of the physical signs. He specifies, —

1st. Visible pulsation of the arteries of the head and superior
extremities ; 2nd. Bruit de soufflet in the ascending aorta, caro-
tids, and subclavians; 3rd. The fremitus, or rushing thrill felt
by the finger in the carotid and subclavian arteries. In con-
junction with these he notes the character of the pulse, which is
invariably full.

“ When a patient affected with this disease,” says Dr. Corri-
gan, “ is stripped, the arterial trunks of the head, neck, and su-
perior extremities immediately catch the eye by their singular
pulsation. At each diastole the subclavian, carotid, temporal,
brachial, and in some cases even the palmar arteries, are suddenly

a Edinburgh Medical and Surgical Journal, vol. xxxvii., pp. 227, 228.

DISEASE OF THE AORTIC VALVES. •

213

thrown from their bed, bounding up under the skin. The pulsa-
tions of these arteries may be observed in a healthy person through
a considerable portion of their tract, and become still more marked
after exercise or exertion ; but in the disease now under consider-
ation the degree to which the vessels are thrown out is excessive.
Though a moment before unmarked, they are at each pulsation
thrown out on the surface in the strongest relief. From its singu-
lar and striking appearance, the name of visible pulsation is given
to this beating of the arteries. It is accompanied with bruit de
soufilet in the ascending aorta, carotids, and subelavians ; and in the
carotids and subelavians, where they can be examined by the fin-
ger, there is felt fremissement, or the peculiar rushing thrill accom-
panying with bi'uit de soufflet each diastole of these vessels. These
three signs are so intimately connected with the pathological
causes of the disease, and arise so directly from the mechanical
inadequacy of the valves, that they afford unerring indications of
the nature of the disease. In order to understand their value, it
is necessary to consider their connexion with the cause by which
they are produced. The visible pulsation of the arteries of the
neck, &c. may be first examined.

“In the perfect stateof the mechanism at the mouth of the aorta,
the semilunar valves, immediately after each contraction of the
ventricle, are thrown back across the mouth of the aorta by the pres-
sure of the blood beyond them, and when adequate to their func-
tion of closing the mouth of this vessel, they retain in the aorta the
blood sent in from the ventricle, thus keeping the aorta and lar-
ger vessels distended. These vessels consequently preserve nearly
the same bulk during their systole and diastole. But when the
semilunar valves, from any of the causes enumerated, become in-
capable of closing the mouth of the aorta, then, after each con-
traction of the ventricle, a portion of the blood just sent into the
aorta, greater or less, according to the degree of the inadequacy
of the valves, returns back into the ventricle, lienee the ascend-
ing aorta and arteries arising from it, pouring back a portion of
-their contained blood, become, after each contraction of the ven-
tricle, flaccid or lessened in their diameter. While they are in this
state, the ventricle again contracts and impels quickly into these
vessels a quantity of blood, which suddenly and greatly dilates

214

DISEASES OF THE VALVES OF THE HEART.

them. The diastole of these vessels Is thus marked by so sudden
and so great an increase of size as to present the visible pulsation
which constitutes one of the signs of the disease.

“That this visible pulsation of the arteries is owing to the me-
chanical cause here assigned is made evident by several circum-
stances. It is most distinct in the arteries of the head and neck,
which empty themselves most easily into the aorta, and of course
into the ventricle. In the arteries of the lower extremities, of even
larger size than those which present it about the head and neck,
it is not seen to any comparative degree, and most generally not
at all while the patient is standing or sitting. It is much more
marked in the arteries of the head and neck in the erect than in
the horizontal posture.”

Since the publication of Dr. Corrigan’s researches, the expe-
rience of many observers has tended rather to confirm every part
of his diagnosis, than to add any new information. Yet there are
some collateral points which are deserving of study.

This disease, which appears to be one of middle life rather
than of youth or old age, and more frequently met with in the
male than the female, is, either in its isolated form, or combined
with an affection of the mitral valves, of common occurrence. It
may be met with in young persons after an attack of rheumatic
carditis, and it is probable, that in a large proportion of the cases
which occur under the age of twenty-five years, the exciting cause
has been an endocarditis. On the other hand, the examples occur-
ring in men from thirty to fifty years of age seldom show a dis-
tinct inflammatory origin.

In many of these cases a general morbid state is to be ob-
served, to which it is difficult to give an appropriate term. It
is a condition approaching to that which favours the deposition
of fatty, atheromatous, and probably tuberculous matter, a condi-
tion of deficient hsematosis,— induced often by excesses or over-
fatigue, and attended by a weakened state of the nervous sys-

tem. That a connexion exists between the atheromatous dia-
thesis and that in which fatty and tuberculous matters are de-
posited must be admitted, even although the researches of Andral,
Lobstein, and Gluge, had not tended to the same result.

We have alluded to the diminished vital energy in this dis-

DISEASE OF THE AORTIC VALVES.

215

ease. This is shown, not only, as Dr. Corrigan has remarked, in
the want of proportion between the impulse of the heart and the
amount of hypertrophy of the left ventricle,— as well as in the in-
jury done by an antiphlogistic treatment, — but also in the cha-
racter of the local inflammations of other organs than the heart,
to which the patients are liable. I have generally found that such
inflammations were of a low kind; that they resisted oidinaiy
treatment; that when, for example, pneumonia set in, which is
not uncommon, it had a spreading, somewhat erysipelatous cha-
racter, resisting local treatment, and not benefited by tartar eme-
tic or mercury, especially the first. It is a common error for piac-
titioners, when called to a case of acute bronchitis or pneumonia
supervening on this condition of the heart, to overlook this pecu-
liarity of constitution, and they are too often surprised at the
rapid sinking of the patient, who, but a few days before, appeared
to be in a safe position.

The injurious effects of a too severe antiphlogistic treat-
ment in these cases is to be attributed, not only to the weakening
of the left ventricle, the hypertrophy of which seems a provision
of nature, but also to the fact, that the entire organism being under
the influence of a depraved chemico-vital condition, is unfit to
bear reduction, or respond favourably to the action of remedies.

If we consider the physical signs of this disease, which em-
brace not only the evidences of regurgitation through a diseased
orifice, but of those of dilatation and hypertrophy of the left
ventricle, we find that the diagnostics given by Dr. Corrigan ap-
ply essentially to the disease when, as it were, it is at its maturity ;
having, on the one hand, passed its first stage, and, on the other,
not yet arrived at the period of depression of the action of the heart.
At both these periods, in fact, the completeness of the signs may
be found wanting. Thus, in the first stage, we may have the
throbbing pulsation of the innominata, and of the carotid and sub-
clavian arteries, with a systolic murmur propagated into these ves-
sels, yet without the second or regurgitant murmur. And again,
in the latter periods of these cases, the throbbing and visible pul-
sation of the arteries cease, at least in the radial artery, and, to a
great degree also in the carotids, while the double murmur under
the sternum remains, though with diminished intensity.' Cases of

216

DISEASES OF THE VALVES OF THE HEART.

this disease occur in which for a long time, the radial pulse has
been characteristic, and yet, for many days before death, there
may be nothing remarkable in the pulse at the wrist.

But, in strong contrast with that condition where, from the
progressive enfeebling of the heart, the arterial throbbing is found
to subside, and, as it were, retreat towards the heart, we must place
a category of cases in which the signs go on augmenting up to
almost the last period of existence. In such cases there is not only
a greatly dilated and hypertrophied left ventricle ( cor bovinum),
but the vital contraction of the organ is unimpaired, or, it may
be, augmented; so that, from many causes, including, possibly, a
dilated state of the aortic orifice, the most violent pulsations of the
arteries all over the body are produced, and the whole trunk pul-
sates like one vast aneurism.

We may divide the cases of permanent patency of the aor-
tic valves into those in which the heart’s action is either not
excited, or even depressed; and those where the enlargement of
the left ventricle is attended by augmented contractile power ; and
it will be found that there is more chance of prolongation of life in
these cases than in those of the former class, notwithstanding
the greater prominence of the symptoms. This may arise from
the disease being in one case accidental, as when it proceeds from
an endocarditis ; while in tire other it is but a sign of a generally
morbid condition of the system, of a special and essential disease,
which, even if the heart affection had not occurred, would as-
suredly, although by some other process, shorten the life of the
patient.

In most cases, however, the fatal termination is preceded by
a gradual failure of the powers of life; and Dr. Corrigan has
shown that, as the contractile power of the left ventricle becomes
less and less, death may take place from the want of arterial sup-
ply. The death is commonly gradual, but may be sudden. I have
already remarked, that sudden death in cases of this kind appears
to be less frequent than in disease of the mitral valves0.

» A case of sudden death, occurring in a patient aged 15, who for five months had
laboured under the effects of inadequate aortic valves, was brought forward by Dr.
Corrigan at a meeting of the Pathological Society, in December, 1841. In this
affection the form of the heart differs remarkably from that observed in disease of the mi-

DISEASE OF THE AORTIC VALVES.

217

A remarkable difference between this disease and the con-
traction of the mitral orifice is the want of that irregularity ol
pulse which so often attends the latter affection. In the disease
of the aortic valves we often observe that the pulse, though full,
i throbbing, and collapsing, is regular. In certain cases an occa-
; sional intermission occurs, but the general character of pulse, as
: to rhythm, and even frequency, is but little altered from the state
of health. It is under these circumstances that the diagnosis is
i most easily made, for the physical signs are much more obscure
when, with inadequacy of the valves, we have irregular action of
• the heart; the arterial throbbing and the to-and-fro murmur then
become much less evident ; so that, at particular periods of the
. case, the diagnosis of the special lesion is difficult.

It is probable that, in some of these cases, a double valvular
lesion exists, and that the mitral as well as the aortic onfice is
engaged. Yet even with the double lesion, the pulse may remain
: singularly regular.

We have already alluded to the occurrence of two forms of
this disease, in which the difference of symptoms depends less on
the imperfect state of the aortic valves than on the condition ol
the left ventricle, especially as regards its vital contractility and
power. In the first class of cases, as Dr. Corrigan has shown,
the symptoms are often obscure, and the disease might escape ob-
servation, unless by stethoscopic examination, and the existence
of visible pulsation of the large arteries. In the second class,
however, we have the symptoms much better marked, and yet
the disease is often of longer duration. I have suggested that

tral valves, as noticed by Dr. Adams (Dublin Hospital Reports, vol. iv.), in which, owing
to the fact that the apex is formed by the right ventricle, the heart presents a somewhat
globular appearance. In the case before us, however, as might be expected, the apex
of the organ is chiefly formed by the left ventricle — (See also Dr. Law s observations on
the same point : Transactions of the Pathological Society, June, 1845.) The globular form
of the heart, however, is not peculiar to enlargement of the right ventricle, for it may occur
in cases of isolated dilatation of either cavity, with or without hypertrophy. Of this, the
case communicated by Dr. Fleming is a good example. Here, it will be recollected, the
heart was globular, owing to the enlargement of the left ventricle. It would be an inte-
resting investigation to determine whether inadequacy of the mitral valves produces a
different result as to the form of the left ventricle from that observed in the open state of
the aortic orifice.

218 DISEASES OF THE VALVES OF THE HEART.

ill these instances the lesion has been originally accidental, not
resulting from a morbid constitutional state. Of such cases, the
following is an example, for which I am indebted to Dr. C. Cro-
ker King.

Case XXIV. — Extensive disease of the Aortic Orifice , with inade-
quacy of the Valves ; Vast hypertrophy and dilatation of the left
Ventricle, probably secondary to an attack of Endo-pericarditis ;
Aggravated symptoms of Angina Pectoris, continuing to recur
for upwards of ten years.

A gentleman, aged 29, of delicate habit, was attacked with
symptoms of pleurisy, and, in all probability, of pericarditis, seven
years before the time that he consulted Dr. King. When the pa-
tient first came under notice it was plain that a great hypertrophy
of the heart had been established, as a strong and extended im-
pulse could be distinctly seen ; the pulse was sharp and sudden,
and occasionally intermitted. From the second left l'ib to the
ninth there was dulness on percussion, extending to the right of
the sternum, and bounded on the left by a line drawn perpendi-
cularly from the centre of the axilla. The whole area of dulness
was about thirty-six square inches. On placing the ear to the
side of the chest a sensation was communicated which was com-
pared by Dr. King to the blow of a bladder filled with fluid, ac-
companied by a peculiar sound, similar to that produced by
placing the finger on the tragus, so as to close the external mea-
tus, and then withdrawing it suddenly ; this was terminated by
a muffled bellows murmur. The second sound was attended by
impulse and murmur, but the latter was much sharper and shorter
than the systolic murmur; this was heard most distinctly at a
point higher than the usual position of the aortic valves.

This patient suffered from paroxysms of angina pectoris, with
an amount and intensity of suffering probably unprecedented.

The paroxysms were preceded by general nervousness, and
increased palpitation, gradually augmenting until the heart’s ac-
tion became tumultuous, accompanied by a sensation of aching
down the arms and legs, with a feeling of lassitude and a de-
sire to sit down, which, however, the patient dare not do, for

DISEASE OF THE AORTIC VALVES.

219

fear of inducing an accession of the paroxysm. After a variable
length of time, perhaps two or three hours, spent in fruitless en-
deavours to ward off the paroxysm, it fairly set in with a sense of
constriction referred to the sternum, as if that bone and the spme
, were being forcibly approximated, and a sensation of the heart
b being torn from the thorax. As the paroxysm proceeded, the
aching pains in the arms were replaced by a sensation as if red-
1, h0t wires extended along the course, especially of the ulnar nerves ;

the heart beat with the most extraordinary violence, causing the
V whole frame to vibrate ; the carotids appeared impatient of the
restraint of the integuments, and every superficial branch in the
[ body could be traced ; at each stroke of the heart, the whole per-
< son appeared to undergo a general dilatation, as if it were one
g great aneurism.

In order to obtain relief, he was accustomed to throw his head
l back, and to extend the spine, as is seen in opisthotonos : the
arms were stretched first downwards, and then elevated above
his head to the fullest extent, in order to give the great pectoral
muscles a fixed point of action, in the hope of relieving the sense
of thoracic constriction. .The position of the patient, his daik,

\ wild, staring eyes, and pallid face; the intensity of his agony, the
perspiration, which at first stood in large drops, and then ran down
' his neck, altogether embodied a scene which baffles description,

; presenting a picture of suffering which could not be imagined
or described.

When this great excitement had subsided, lie felt perfectly
tranquil : he appeared like one relieved from some desperate
« struggle, and was full of vivacity, wit, and humour. When a
paroxysm was to occur at night, the patient awoke with a sensa-
: tion resembling night-mare, and started up from bed; the slight-
est exertion, such as merely throwing the quilt about him, was
• sufficient to bring on an attack, and on this account he was accus-
I tomed for a long time to sleep in his clothes. On many nights,
worn out by his efforts to ward off an attack, and having been
overcome by sleep in the erect position, he would fall to the
ground, and start up in a paroxysm of unusual severity. Latterly
the paroxysms became more and more frequent; the mere act of
eating induced them, so that at times lie was afraid to taste food,

220

DISEASES OF THE VALVES OF THE HEART.

or if he fancied himself so situated that he could not assume at
will a posture of relief, this feeling was itself sufficient to induce
a paroxysm ; in fact, the slightest moral cause was enough to
produce it : for a length of time he was unable to see any
friend ; he usually came down stairs at five o’clock, and if any
person took notice of him, or inquired how he was, he at once
got an attack. He walked about the room, or leaned upon the
mantel-piece during dinner, never sitting down to a meal.

He had always experienced the greatest relief from stimulants,
so that without any real desire for them, he was in the habit, for
many years, of drinking daily eighteen tumblers of punch — an at-
tack of delirium tremens, however, determined him to abandon
this custom, and to substitute opium ; by great management and
forbearance he restricted himself to one pint of laudanum in the
week, provided it was made of the best opium. None of the salts
of morphine, or even the black drop, except in very large doses,
produced the effect desired. Other stimulants, for instance, Hoff-
man’s anodyne, if combined with the salts of morphine, afforded
relief. About every six months he suffered from partial sup-
pression of urine, accompanied by pain across the region of the
kidneys. Towards the close of the case, anasarca, confined
exclusively to the lower extremities, set in ; there had never
been any puffiness of the face, but it is to be remembered that
he did not lie down, as the recumbent position appeared to impede
the heart’s action; there never was dyspnoea nor cough. He
was at length found dead in his bed, after having been seen about
an hour previously in his usual position, sitting, or rather prop-
ped up, in bed, when he expressed his satisfaction at having
passed a good night. The servant, on returning about an hour
afterwards, found his master dead.

His death, it would appear, had been perfectly easy, as he was
in the same position as when last seen during life.

During the entire progress of the case, which was of ten years’
duration, there had never been the least evidence of congestion,
local determination of blood, or interrupted circulation. No epis-
taxis, haemoptysis, suffusion of eyes, headach, or frightful dreams,
occurred; nor was there, as before remarked, the slightest cough
or dyspnoea.

DISEASE OF THE AORTIC VALVES.

221

At the post mortem examination, thirty hours after death, on
throwing up the sternum and cartilages of the rib3, an immense
pericardium alone presented itself, which was found to he univer-
sally adherent to the surface of the heart, thus corroborating the
opinion formed as to the origin of the disease. The base of the
heart was situated in an unusually high position ; the left ven-
tricle was hypertrophied and dilated to an extraordinary degree ;
the weight of the heart, after the coagula were removed, being
forty-four and a half ounces. The hypertrophy was confined to
tithe left side; the right ventricle did not nearly reach the apex
of the heart ; in fact, not the apex alone, but almost all the

lower part of the heart, was formed by the left ventricle ; the

-sinuses of the aortic valves were almost filled by rugged cal-
,-careous deposits. The double bruit, alluded to at the com-
mencement of the case, was evidently produced as follows: —
The soft, prolonged, first bruit, by the passage of the blood over
t the cardiac surfaces of the valves, while the roughness of the se-
cond bruit was due to the regurgitation of the blood over the

rouo-hened arterial surfaces of those valves, the calcareous de-

posit having taken place at their aortic surface. The shortness
of the second bruit might be accounted for by the rapidity of the
1 heart’s action, as the pulse generally averaged 1 20, so that the
frequency of the ventricular systole prevented a long duration of
the regurgitant murmur; the aortic orifice was perfectly free,
though the valves were inefficient ; the aorta itself appeared to
I be thinned and slightly dilated. The kidneys were enlarged,

• slightly indurated, and mottled, presenting a number of minute
. asperities.

The dissection did not reveal any further change to which the
immediate cause of death might be attributed. There was no ex-
1 travasation into the brain. Taking into consideration the undis-
: turbed position of the body, as well as other circumstances, Dr.

King inclines to the opinion that the death was caused by
■ syncope.

Any medicine of a depressing nature, such as digitalis, was
sure to aggravate his distress ; saline purgatives had also a similar
effect.

From the enormous size of the heart it might natufally be

222

DISEASES OF THE VALVES OF THE HEART.

expected that the corresponding part of the chest would be pro-
minent, but it was, on the contrary, flattened.

SIMULATION OF ANEURISM.

As might be expected, the disease is often mistaken for aneu-
rism of the aorta, or innominata; an error not only injurious to
medicine, but productive of the worst consequences to the patient.

I have known this error to be more frequently made in cases
where the disease was recent, and exhibiting well-marked impulse {
at the upper sternal region within a short space of time. On'the
other hand, Dr. Corrigan gives an example of very chronic disease f
in which the pulsations in the region of the innominata were so
strong, that no doubt was ever expressed that the case was not one
of aneurism. On dissection, it was found that the aorta was thinned
and dilated, so as to cause imperfection in the closing of the valves, j
and the dilatation extended to the innominata, carotids, and sub-
clavian arteries. This author well observes, that “ an acquaint- |
ance with the disease under consideration, and a knowledge of the
fact that a violent throbbing at the root of the neck, or notch of
the sternum, may arise from another cause than aneurism, will
prevent the forming of a rash opinion on the cause of the violent
throbbing. This throbbing may proceed from aneurism, or may
arise from inadequacy of the aortic valves. When it proceeds from
aneurism of the arch, or of the arteria innominata , it is confined to
the vessel or the region of the vessel affected ; the other trunks
arising from the arch present only their natural, or even a dimi-
nished pulsation, and there is in the trunks arising from the arch
neither bruit cle soufflet nor fremissement. On the contrary, when
the throbbing at the notch of the sternum, or in the region of the
arteria innominata, is from inadequate aortic valves, all the larger
trunks arising from the arch pulsate in an equal degree, or with
trifling differences, arising merely from the relative sizes of the
vessels, or their relation to the surface, and they are never at any
time without bruit de soufflet and fremissement.

“Not only in relation to treatment, but in regard to the pa-
tient’s mental anxiety, it is of importance to be aware, that inade-
quacy of the aortic valves may, by this violent pulsation at the

disease of the aortic valves.

223

root of the neck, closely simulate aneurism of the arch of the
aorta, or the root of the arteria innominata. In aneurism of the
aorta, life is not for a moment secure, and it may be necessary that
even for a remote hope of cure the patient should totally abstain
from all exertion. In permanent patency of the mouth of the aorta
the fatal result is never sudden; and, under proper restriction, the
patient is not only able to lead an active life for years, but is ac- ,
tually benefited by doing so”a.

But aneurism and permanent patency of the valves occur
in combination. When the diagnosis of aneurism comes before
us we shall return to this subject, and here only remark, that
: the error of taking the disease of the aortic valves for aneurism
a arises not only from want of knowledge of the former disease,
but from inaccurate notions as to the signs and history of aneu-
rism itself. Thus, many believe that bellows murmur is always
[ present in aneurism, and hence take it as a sign of the disease.

. And, again, it is held that aneurism necessarily produces hyper-

• trophy of the heart ; and so this condition, so constantly present in

; permanent patency of the orifice, is held as an additional proof of
the existence of aneurism. Yet the occurrence of bellows mur-
1 mur in the artery, combined with the signs of hypertrophy of

• the left ventricle, which is the rule in permanent patency, is any-
i thing but constant in aneurism.

1 have known this disease to be mistaken for aneurism of the
abdominal as well as the thoracic aorta. When we consider,
i that in confirmed cases of this disease, with an active left ven-
i tricle, all the arteries exhibit an increased pulsation, and recol-
lect the law of the production of increased action of vessels in the
vicinity of organs when in a state of irritation, we can understand
how it might happen that in a person already labouring under in-
creased action of the abdominal aorta, a local augmentation of
that action would give rise to extraordinary pulsations, simulating
aneurism of the abdominal aorta. In such a case, too, should
there be an enlargement of the left lobe of the liver, we may
have, for a time at least, a violently pulsating tumour in the epi-
gastrium; yet it may happen that in a few days the symptoms
may subside, and the patient, if his system has not been disturbed

a Edinburgh Medical and Surgical Journal, Vol. xxxvii., pp. 23G-237.

224

DISEASES OF THE VALVES OF THE HEART.

by reducing treatment, or bis mind agitated by being told that
be has so terrible a disease as abdominal aneurism, be restored to
bis ordinary condition.

In such a case the attention of the practitioner must be directed
to the following points :

1. The absence of the usual symptoms of abdominal aneurism.

2. The fact that the bellows murmur is not confined to the
vessel supposed to be the seat of aneurism, but is heard in the
thoracic aorta, and at the base of the heart.

3. The throbbing pulsation of the femoral arteries, which,
as in the case of the carotids, may also present murmur.

Finally, he should suspect that the disease was not aneurism,
from the existence of symptoms of constitutional irritation.

We might inquire whether, under circumstances similar to
the preceding, an aneurism of the thoracic, as well as the ab-
dominal aorta, might be simulated. On this point I have no
observation to bring forward, and indeed there is less probability
of sympathetic excitement of the artery in the thorax than in the
abdomen, in which we see so many examples of excited action,
even without inadequacy of valves. It is common in hysteria,
and may be met with in various irritations of the digestive sys-
tem, or as an attendant on menstruation or the earlier stages of
pregnancy.

As bearing on the history of augmented local action of arte-
ries, with previous inadequacy of the aortic valves, the following
case is important. The patient was under the care of Dr. Graves
and myself during the greater portion of his long-continued and
extraordinary ailment.

Case XXV. — Long-existing signs of Inadequacy of the Aortic Valves;

Persistence of symptoms simulating Rheumatic Fever ; Local

A rterial Excitement: Cessation of Pulsation in the left Radial

Artery; Death.

A boy, aged , who had for many years presented signs of

a permanently patent aortic opening, was attacked by the illness
which terminated his life in the beginning of March, 1851. The
period of commencement of the disease of the heart could not be

DISEASE OF THE AOIITIC VALVES. '

225

accurately determined, but that a to-and-fro murmur had existed
at the base of the heart for many years is certain. His last illness
commenced by symptoms resembling gastric irritation, of a re-
mitting character, attended with irregular shivering fits, which
continued to recur for a great length of time. The first indication
of anything like rheumatic disease was the sudden supervention of
pain in the calf of the leg. The paroxysms of shivering some-
times occurred within a few hours of one another, and wrere suc-
ceeded by high fever, during which the pulse at the wrist was
singularly hard and thrilling; yet the action ol the heart, al-
though it was to a certain degree excited, was not proportionate.
He complained much of the pulsation and noise in his head ; and
on one occasion he said that he felt as if his brain was acted on by
a churn-dash. These symptoms were aggravated by the use of
opium.

Soon after this period the disease assumed a character which
it preserved with singular constancy up to the period of death.
The patient was liable to attacks of shivering, followed by high
fever and perspiration, almost every one of which was attended
with a local irritation, simulating arthritis, and yet having this cha-
racter, that the inflammatory action was more in the vicinity of
the joint than in the articulation itself. The intervals between
the rigors varied from eight to forty-eight hours, and no treat-
ment had any effect in controlling the disease. This patient
never presented any true form of arthritis. Thus, when the
ankle appeared to be attacked, it was found that there were
no signs of effusion into the joint, but the swelling, heat and
soreness engaged the dorsum of the foot; so, also, when the knee
was complained of, there was no tumefaction of the articulation,
but a space of two or three square inches above the patella was
the seat of disease. When the hand was engaged, it was along
the metacarpal bones rather than in the joints, that swelling and
tenderness were perceived. Finally, the local irritation conse-
quent on each attack of shivering sometimes appeared in the
most unusual situations, — the eyelid, the nose, and the insertions
of the nails, were often the seats of this ephemeral irritation.

In the earlier periods of this singular case, the action of the
heart was occasionally excited, but this liability disappeared, and

VOL. i.

226

DISEASES OF THE VALVES OF THE HEART.

the organ remained singularly tranquil, though still presenting
the double bellows murmur propagated into the arteries. One of
the most remarkable circumstances attending the case was the ex-
traordinary excitement of the arterial pulse in the vicinity of the
various local irritations. It is utterly impossible to convey in words
any idea of the character of the pulsation, as observed in the
anterior tibial artery and its branches. When the foot became en-
gaged, we had then, with a tranquilly acting heart, and a feeble
and compressible radial pulse, a pulsation so vehement and
sharp that the impulse might be compared to the blow of a steel
hammer on an anvil, conveying the idea that the whole foot was
on the point of being burst and torn to pieces at every throb of
the artery.

The disease having continued unmitigated for three months,
it was observed that after one of the attacks in the left hand, the
temperature of the arm was found to be much reduced, and the
pulse at the wrist to have become very small and indistinct. Vo-
luntary motion remained. A fortnight before this he had had a
severe attack of pain in the left biceps. We soon found that no
pulsation could be detected in the fore-arm, and that it was hardly
perceptible in the upper portion of the brachial artery. In the
course of about a fortnight, a feeble pulsation returned at the
wrist; but there was no arrest of the fell disease which was
consuming the patient. It continued to repeat itself, from day
to day, with but little change, until at length the sweats be-
came colliquative. Diarrhoea set in, and signs of congestive
pneumonia closed the struggle, which continued for a period of
nearly four months, resisting all treatment. The rigors occurred
about every second or third day, until the last month of Ins disease,
when the fever became more continued ; and every rigor was fol-
lowed by the peculiar local irritations, attended with the extraor-
dinary local arterial throbbing — now in one part of the system,
and now in another. There was no dissection.

Whatever may have been the nature of this disease, which re-
sisted the use of bark, opium, mercury, iodine, colchicum.and stimu-
lants, the case is eminently instructive as an example of local ex-
citement of arteries to an extraordinary extent, occurring in con-
nexion with ephemeral irritations, and in a case of pcimanently
patent aortic opening of long standing.

DISEASE OF THE AOKTIC VALVES.-

227

There are few conditions more obscure in their nature than
the local excitement of arteries, and few symptoms more singular
than this local excitement, when it arises in a case of inadequate

aortic valves.

That this disease was not arthritis is certain ; and I cannot even
offer a suggestion as to its nature, unless that we might suppose
it to have been some form of erratic or metastatic arteritis.

With regard to the duration of the first stage of a disease
which is to end in permanent patency of the aortic valves, there
is a great variety observed. We meet with patients somewhat
advanced in life, whose appearance indicates their liability to
disease of the heart; they are generally of a full habit; they
suffer from dyspepsia, and often exhibit a tendency to gout. Un-
der the influence of temporary derangement of the stomach, these
patients may complain of throbbing in the head, and of uneasy
sensations, which draw attention to the state of the heart, when it is
discovered that the pulse is hard, yet without the collapsing cha-
racter observed in permanent patency of the aortic valves. The arte-
rial pulsations are not visible, and it often happens that the symp-
toms maybe removed, even for a long period, by treatment directed
to the digestive system. Yet these patients present a permanent
valvular murmur, which is systolic, but single, and propagated
into the aorta; it is loudest at the base of the heart, and fre-
quently absent to the left of the nipple, the second sound re-
maining clear. Such patients may continue in this state for a
great length of time, and enjoy an excellent state of health, and
are often able to take active exercise without distress of respira-
tion. I have at present under my care a gentleman who has for
upwards of two years laboured under this disease, yet who is able
to enjoy the most active field-sports, and even walk up a long
and steep hill without impediment to respiration. That such
cases are of frequent occurrence I have no doubt; and the
immunity from progressive disease of the heart seems to arise
from this, that as the aortic valves remain competent to close
the orifice, the patient escapes the effects of regurgitation.

The murmur in permanent patency of the aortic valves is
generally double. It may, however, be single and systolic,
or single and regurgitant. It is generally low and soft, and

q 2

228

DISEASES OF THE VALVES OF THE HEART.

without musical tone. On the other hand, in cases of great and irre-
gular ossifications at the mouth of the aorta, a musical murmur, pro-
pagated into even remote arteries, and sometimes so distinct as to
be audible at a distance from the patient, may exist. But still, we
may notice a loud musical murmur in connexion with the general
signs of permanent patency. Professor Banks lately exhibited at
the Pathological Society a specimen of diseased and inadequate
aortic valves. Enormous vegetations, and masses of a soft athero-
matous matter, filled the sinuses of the valves, and covered their
ventricular surfaces. When water was poured into the aorta, it
made its way into the ventricle, and there seemed a greater facility
for regurgitation than for the passage of fluid in the direction of
the aorta. A portion of this atheromatous deposit, more than an
inch in length, with a narrow base, stretched freely upwards into
the aorta, where it doubtless vibrated like the tongue of a Jew’s
harp. In this case a very loud musical murmur was transmitted
along the aorta, and the arteries presented visible throbbing, as
in the ordinary disease of the orifice. The patient died aftei a
paroxysm of dyspnoea, the first which had occuired duiing the
progress of the case.

DIAGNOSIS DERIVED FROM THE STATE OF THE CAVITIES.

Having now taken a general view of the diagnosis of valvular
disease, as studied with reference to the practice of medicine, we
may turn to the labours of Forget, one of the latest writers on
diseases of the heart, and inquire how far he is justified m declar-
ing that the law of retro-dilatation furnishes us with such fixed
principles, as that its establishment should mark an advance in diag-
nosis. It is to be noticed, in the first place, that the doctrine of the
liability to dilatation in the cavities of the heart, when, from
obstruction, they are impeded in their efforts to empty themselves
in the natural direction, is not new ; indeed, the author ob-
serves that he does not claim it as such, but maintains that lie
has first established it on a firm foundation, and made it an im-
portant element in diagnosis. „

The diagnosis of the seat of valvular disease at the left side of
the heart, according to Forget, is easily attainable. He has shown

DIAGNOSIS DERIVED FROM THE STATE OF THECAVITIES. 229

the difficulty of distinguishing, by acoustic signs, between the affec-
tions of the right and left valves, a difficulty long before admitted
by practical physicians. He maintains, also, that we cannot with
safety determine the isolation of disease in the mitral or the aor-
tic valves, if we confine ourselves to the study of the seat and
character of sounds; so that, bearing in recollection the greater
frequency of diseases of the left, as compared with those of the
right valves, and assuming that a permanent bellows murmur, of-
ten rough and attended with fremitus, is the great indication of
valvular disease, we are to conclude, that with such a murmur,
the disease is in the aortic orifice when the left ventricle is dilated,
and it may be, hypertrophied, and in the mitral valves, when the
left ventricle is unaffected.

But in the cuse of mitral disease, the law of retro-dilatation
is still in force. The left auricle becomes dilated, as indicated
by dulness on percussion, and, subsequently, the right cavities
of the heart. Again, the fulness of the praecordial region ob-
served in active aneurism of the left ventricle will be wanting,
the pulse will be small, and without the hardness and vibration
which indicates increased power of the left ventricle. One diag-
nostic more is given, which cannot be admitted, namely, that the
impulse of the heart is feeble. We know that when, from con-
traction of the mitral orifice, the right ventricle becomes enlarged,
there is generally a strong impulse; and in connecting the dul-
ness on percussion with feeble impulse, Forget has indicated
two diagnostics, which seem incompatible.

But if we inquire whether the law of retro-dilatation has in
reality such value, as that its establishment marks a step in advance
in the science of diagnosis, a very doubtful answer must be returned.
This dilatation a tergo is not constant, nor, when it occurs, can it be
always recognised with certainty or facility. In how many cases
of disease of the aortic valves are the signs of hypertrophy and
dilatation of the left ventricle wanting? or, if we consider the
contraction of the mitral orifice, by what means are we to demon-
strate the dilatation of the left auricle ? for there is a great differ-
ence between theoretical diagnostics and those justified by ex-
perience. A case is detailed by Forget, in which, in a patient
aged 65, who laboured under chronic bronchitis, there were ir-

230

DISEASES OF THE VALVES OF THE HEART.

regular pulsations with little impulse. A slightly rough bellows
murmur attended the second sound, which was not propagated
into the aorta. The diagnosis of disease of the mitral orifice was
made. When the heart was displayed on dissection, the left ventri-
cle was found to be greatly hypertrophied, upon which Forget
immediately altered his diagnosis, and declared that aortic valve
disease existed. The aortic valves were found ossified, shortened,
and insufficient, while the mitral valves were healthy ; and this case
is quoted as a confirmation of the law. But we should have a larger
knowledge before we designate as a law what is yet but the chance
consent of a limited number of observations. Let us recur to the
case by Dr. Fleming, and inquire how far the law of retro-dilata-
tion would apply to it. Here was a case of valvular murmur, with
a small, weak, and irregular pulse, and without signs of active en-
largement of the left ventricle, but, on the contrary, with evi-
dences of enfeebled power of the heart ; and yet a great enlarge-
ment of the organ, owing almost entirely to the hypertrophy and
dilatation of the left ventricle, was found. In such a case, before
the heart was opened, Forget would have made the diagnosis of
lesion of the aortic valves, yet the disease was in the mitral opening,
while the aortic valves were perfectly healthy and competent to
close the orifice. It must be also borne in mind that retro-dilatation,
is a condition consequent on the valvular disease, and that the pe-
riod when it occurs to such a degree as to become available in
diagnosis is infinitely varied in different cases; years may elapse
with the existence of a valvular murmur before the cavity be-
comes dilated, and indeed, in some cases, death takes place by
syncope, asphyxia, or rupture of the valves, without the signs of
retro- dilatation having ever been manifested. We cannot say
why in one case the cavities become hypertrophied and dilated,
while in another an indisposition to this change appears to exist;
and it is obvious that for the production of the change in question,
something more than mere mechanical obstruction is necessary.
There must be some vital alteration or organic change in the
muscular structures, the presence of which favours the dilatation
or hypertrophy, while its absence preserves the integrity of the
cavities of the heart.

For the occurrence of a retro-dilatation must not be considered as

DIAGNOSIS DERIVED FROM THE STATE OF THE- CAVITIES. 231

merely a mechanical result of obstruction, nor that of retro-hypertro-
phy as a change necessary to overcome that obstruction. Great nar-
rowing of the aortic opening may exist without hypertrophy or
dilatation of the ventricle, a fact which is familiar to every patho-
logical anatomist. I have seen more than one case in which,
although the orifice was so narrowed as to make us wonder how
the circulation was carried on, the left ventricle was unchanged.
Professor Smith has met with several instances of this kind ; and,
on a late occasion, has found a contraction of the left ventricle
(the concentric hypertrophy of authors) to coincide with extreme
obstruction at the aortic orifice.

If, then, we reflect on these facts, and call to mind the many cases
of valvular murmur continuing for years without the symptoms or
signs of alteration of the cavities, and the circumstance that, even
in the cases of retro-dilatation, the change is secondary to the
valvular lesion, we must hold that, in a large number of cases, we
cannot avail ourselves of the signs of enlargement of the cavities
in the diagnosis of valvular disease. Forget has not given suf-
ficient weight to the influence of regurgitation in producing the
dilatation and hypertrophy of the cavities. There is little doubt
that it has an important effect in causing dilatation; and, so far
as hypertrophy is concerned, its influence must also be consider-
able.

This much may be admitted, that, in cases of valvular mur-
mur, the existence of signs of enlarged cavities is to be taken as
corroborative evidence that the murmur indicates an organic dis-
ease of the valves. Considered with reference to the special diag-
nosis of disease of the aortic and mitral openings, all that For-
get has established was announced long ago by Dr. Adams and
Dr. Corrigan, the first of whom showed the value of the signs of
enlargement of the right ventricle as a diagnostic of mitral dis-
ease ; while the second established that hypertrophy and dilatation
of the left ventricle was attendant on the permanent patency of
the aortic valves.

There yet remain for consideration three forms of disease of
the aortic valves. One of these, consisting of extreme ossification,
with irregular growths stretching down into the ventricle, has
been already noticed at the commencement of this chapter. Of

232

DISEASES OF THE VALVES OF THE HEART.

this condition, the principal indications are the signs of an hyper-
trophied left ventricle, and the production of a musical murmur,
which is systolic, propagated even into distant arterial branches,
and often so loud as to be audible at a considerable distance from
the patient.

The two remaining cases arc distinguished by the existence,
as a permanent condition, of a weakened left ventricle, often the
result of fatty degeneration. In one case we have the regurgitant
murmur of permanent patency, while, in the other, the murmur
is single but systolic, and propagated into the aorta and its branches,
the valves, though diseased, being competent to close the orifice.
The leading characteristics of both these cases are the slow pulse
and the repetition of the pseudo-apoplectic symptoms; but we
shall defer their more full consideration until we speak of the
fatty disease of the heart.

We may now state, in separate propositions, those conclusions,
which have a practical importance with reference to valvular
disease.

RECAPITULATION.

1. That cases of valvular affection may be divided into two
classes, in one of which the disease has been produced by inflam-
mation, while, in the other, it appears to arise independently of
this condition.

2. That in the first class of cases, a period arrives in which,
although the disease is progressive, there is no evidence of its
being of an inflammatory nature.

3. That hence it is generally improper to persist in an anti-
phlogistic treatment of valvular disease beyond a certain period
of time.

4. That the determination of the actual seat and nature of a
valvular disease is of less importance than that of the vital and
mechanical state of the heart.

5. That a permanently patent state of the orifices is the or-
dinary result of all valvular diseases. This condition may or may
not be attended with contraction, or the orifices may be dilated.

6. That the period when inadequacy of the valves supervenes,
varies greatly in different cases.

RECAPITULATION.

233

7. That hence, two scries of phenomena may occur ; in the
first wc have tire signs of disorganization without inadequacy; in
the second, those of inadequacy are added.

8. That the distinctness of valvular murmur cannot be taken
as being proportionate to the amount of disease.

9. That a complete cessation of murmur may coincide with
the advance of disease.

10. That the cessation of murmur, under these circumstances,
has been only observed in connexion with contraction of the ori-
fice ; it has not been observed in cases of free regurgitation.

11. That absence of murmur does not necessarily imply ab-
sence of valvular disease, especially if there be symptoms of disease
of the cavities.

12. That the number of cases in which we are warranted in
making a special diagnosis of valvular disease is small.

13. That the number of pathological conditions competent to
cause such changes in the valves as will produce murmur is very
great.

14. That in the earlier periods of valvular disease, murmur
may not occur, although the disease be progressive.

15. That even in chronic cases, the development of murmur
may be sudden.

16. That the disorganizing process may advance with great
rapidity, or with slowness, and that, in some cases, it appears to
be really arrested.

1 7. That the irregular action of the heart is much more related
to the state of the cavities than to that of the valves.

18. That we may observe the sudden development of the
symptoms as well as of the physical signs of chronic disease of
the heart.

19. That three conditions of the heart, considered in its vital
relations, may accompany or follow valvular disease : —

a. Increased force of the heart.

b. Diminished force, with rapidity and irregularity of action.

c. Diminished force, with remarkable slowness and compa-

rative regularity of action.

20. That the law which regulates the production of.the alte-

234

DISEASES OF THE VALVES OF THE HEART.

ration of the cavities, which follows on valvular obstruction, with
or without inadequacy, is still undetermined.

21. That considering the rarity of organic change in the
valves at the right side of the heart, and the difficulty or impossi-
bility of their special diagnosis, we may, in a practical point of
view, limit our considerations to the diseases of the mitral and
aortic valves.

22. That in the diseased and permanently patent condition
of the valves of the pulmonary artery, a double murmur at the
base of the heart, not propagated into the aorta, and not attended
with general arterial throbbing, has been observed.

23. That in most cases of organic disease of the valves at the
right side of the heart there is either an open foramen ovale, or
a deficient ventricular septum.

24. That the most frequent result of disease of the right auri-
culo-ventricular valves is but the exaggeration of their natural in-
sufficiency.

25. That we cannot by the ordinary acoustic or tactile signs
determine the existence of dilatation of the right auriculo- ventri-
cular orifice.

26. That reflux pulsations in the veins of the neck, and occa-
sionally in those of the upper extremities, indicate regurgitation
into the right auricle.

27. That hence they may be taken as indicating the insuffi-
ciency *of the valves, and may have, as their remote cause, morbid
conditions of the pulmonary artery, the lung, or the left side
of the heart.

28. That of these different lesions the most frequent is con-
traction of the mitral orifice.

29. That the venous pulse thus produced may be permanently
present, or only developed during an attack of cardiac asthma.

30. That the pulsations in the jugular veins are synchronous
and isochronous with the ventricular systole.

31. That we must not depend on any acoustic character of
murmur, nor even on its exact seat, for the diagnosis of valvular
disease. It is requisite to combine with these considerations those
of the history and symptoms of the case, as well as those which

RECAPITULATION.

235

have reference to the state of the pulse, the force of the heart,
and the condition of the lung and liver.

32. That all diagnostics depending solely on the tone, cha-
racter, and seat of murmur, are more or less doubtful.

33. That although by acoustic signs we may often determine
the insufficiency of a valve, yet there are no means by which, from
the stethoscope alone, we can declare the cause of that insuffi-
ciency.

34. That the diagnostics between the contraction and dilata-
tion of any of the orifices, founded on acoustic phenomena, are to
be rejected.

35. That organic and ansemic murmurs may co-exist.

36. That there are no distinctive symptoms of disease of the
mitral valves, when it is uncomplicated with alteration in the vital
or mechanical state of the cavities.

37. That its principal physical indication is a murmur which
is systolic, but not propagated into the arteries, and loudest to-
wards the apex and to the left side. This may or may not be at-
tended with fremitus.

38. That the most common result of contraction of the mitral
opening is pulmonary congestion, with enlargement of the right
cavities of the heart.

39. That under these circumstances, from the preponderance
of the right ventricle, a globular form of the heart may be pro-
duced.

40. But the globular form of the heart may exist with a
dilated mitral opening, attended with enlargement of the left ven-
tricle, while the right remains unaffected.

41. That the combination of a contracted state of the mitral
opening, with permanent patency of the aortic valves, is of fre-
quent occurrence.

42. That under these circumstances, we may occasionally ob-
serve both the mitral and the aortic murmurs.

43. But that the absence of a mitral murmur, in a case
of permanent patency of the aortic valves, does not neces-
sarily imply that the auriculo-ventricular opening is free from
disease.

44. That in cases of mitral contraction moveable coagula may

236 DISEASES OF THE VALVES OF THE HEART.

be formed in the left auricle, wbicli may, by occlusion of the open-
ing, become a cause of sudden death.

45. That with the progress of contraction the mitral murmur
may gradually subside, and ultimately become extinct, so that
with the increase of disease, we have decrease and cessation of
murmur.

46. That this cessation of murmur may coincide with a per-
manently patent though contracted opening.

47. That inasmuch as most cases of mitral murmur are sys-
tolic, they are to be held as regurgitant. We cannot, by acoustic
signs, distinguish between the direct constrictive and the regurgi-
tant murmurs.

48. That the interscapular murmur may attend constriction
or dilatation of the mitral opening, but appears more allied to the
latter than to the former condition.

49. That the interscapular murmur may be consequent on a
recent and acute disease of the heart.

50. That the existence of a pre-systolic murmur, which theo-
retically should imply that it attended the passage of blood from
the auricle into the ventricle, does not justify the diagnosis of
absence of regurgitation through tire mitral orifice.

51. That the physical signs of the permanent patency of the
mitral and that of the aortic orifice generally differ in this, that
in the former case the murmur is single, in the latter double.

52. That in combination of disease of the aortic and mitral
valves the whole of the mitral, and the first part of the aortic
murmur, are the result of tire ventricular contraction ; the mitral
being regurgitant, the aortic direct. But the second portion of
the aortic murmur is regurgitant, and its corresponding pheno-
menon in the mitral opening, which, if it occurred, would be
direct, is generally wanting.

53. That the pseudo-apoplectic symptoms, such as occur in
fatty degeneration of the heart, may be also observed in cases of
permanently patent and dilated mitral orifice.

54. That a murmur, loudest at the base of the heart and pro-
pagated into the arteries, indicates disease of the aortic valves.

55. That this murmur is single and systolic when the valves
are competent; but when they are inadequate it is generally
double, but may be single and diastolic.

recapitulation.

237

50. That the effect of regurgitation is to produce the signs in-
dicated by Dr. Corrigan, namely, the visible arterial throbbing,
the collapsing pulse, and the fremitus attending the pulsations of
the arteries of the neck.

57. That in the progress of a case of inadequacy of the aortic
valves three stages may be observed. In the first, the valves,
though diseased, are still competent to close the orifice, and there
is direct murmur propagated into the arteries, but without the vi-
sible throbbing of the vessels ; in the second, we have the regur-
gitant murmur existing in the heart and arteries, together with
the visible throbbing of the vessels, and increasing signs of en-
largement of the left ventricle ; while in the third we may ob-
serve, that while the to-and-fro murmur in the heart and the aorta
remains, the pulse becomes less characteristic, and the visible throb-
bing subsides; this condition marks the gradual decline of the
force of the heart and of the general strength, and indicates the
approach of death.

58. That the duration of the first stage, or that preceding the
permanent patency, varies in different cases.

59. That this disease may be induced by carditis, or arise in-
dependent of such a condition.

60. That cases of permanent patency of the aortic valves, ori-
ginating in endocarditis, arc more often met with in the young
than in middle-aged persons.

61. That in many cases this disease seems to be secondary to
a weakened state of the system at large.

62. That the local inflammations which may arise in cases of
this affection have generally an asthenic character.

63. That in practice we may divide cases of this disease into
two classes, the distinction being founded upon the state of activity
or feebleness of the left ventricle.

64. That the disease may be mistaken for aneurism, not only
of the thoracic, but of the abdominal aorta.

65. That in cases of permanently patent aortic orifice, the oc-
currence of local irritations, whether in the abdominal viscera
or the extremities, may produce a localized and extraordinary
arterial throbbing, which disappears on the subsidence of its
cxciting cause.

238

DISEASES OF THE VALVES OF THE HEART.

66. That disease of the aortic valves, with or without inade-
quacy, may co-exist with fatty degeneration of the left ventricle,
under which circumstances we observe a permanently slow pulse,
with a murmur, on the one hand, single and direct, and on the
other, double, in consequence of regurgitation.

67. That it is occasionally met with in cases of feeble dilated
hearts, when its diagnosis becomes more difficult from the small-
ness of the pulse and the rapid and irregular action of the heart.

68. That when evidences of dilatation of any of the cavities
co-exist with valvular murmur, these evidences are calculated to
strengthen the diagnosis of valvular disease.

69. That the signs of dilatation, with or without hypertrophy,
will have still more value when the dilatation is manifest in
that cavity in which the orifice of exit appears to be the seat
of murmur.

70. But that the co-existence of a dilated left ventricle with
valvular murmur may be observed in insufficiency and dilatation
of the mitral opening, with healthy aortic valves, a pathological
fact opposed to the law of retro-dilatation.

APPENDIX TO THE PRECEDING CHAPTER.

Since the introductory matter at the commencement of this
chapter was printed, I have obtained the last edition of the Trea-
tise by Skoda on Auscultation and Percussion ; and as the views
of this observer, as to the sounds of the heart, are worthy of
careful consideration, and to a certain extent agree with those
which I have put forward, no apology is necessary for the intro-
duction of the following extract" : —

“ The two Ventricles , the Aorta and the Pulmonary Artery, severally

produce both the first and second sound perceptible in the region

of the Heart.

“ I believe that vivisections are not sufficient to solve the ques-
tion of the origin of the sounds audible in the region of the heart,
and that, to accomplish this, observations on persons in health as

» Abliandlung iiber Perkussion und Auslcultation, von Dr. Joseph Skoda, vierte
Auflnge. Wien, 1850.

VIEWS OF SKODA.

239

well as in disease, and careful comparisons of the phenomena ob-
served during life, with the results of post-mortem examinations,
are indispensable.

“ An observer, whose ear is practised in auscultation, will, if
he has the opportunity of examining many healthy and diseased
individuals, find the truth of the following statements : — The sounds
which depend on the motions of the heart, are not equally dis-
tinct and strong in different perfectly healthy individuals ; in one
they will be scarcely perceptible and not accurately defined ; in
another they will be, on the contrary, very clear, even in some
measure ringing ; in one case they can scarcely be heard in the
cardiac region itself, while in another they are plainly audible
over almost the entire anterior surface of the thorax, and even ex-
tend to the back: in manyjDersons we hear these sounds particu-
larly plainly over the part of the thorax against which the heart
beats; while in others, the same region gives only indistinct tones,
which, on the contrary, are much more plainly perceptible over
the pulmonary artery and aorta.

“ When we compare the sounds in the part of the thorax,
against which the heart beats, with those heard above the base
of the heart, in the situations under which the pulmonary artery
and aorta lie, we shall often observe, that in the cardiac region
the first sound, that is, the sound synchronous with the impulse, is
longer than the second ; but that, above the base of the heart,
the accent falls on the second sound.

“ If we compare the sounds in that part of the thorax, against
which the apex of the heart strikes, and which corresponds to the
situation of the left ventricle, with the sounds audible, at the same
height, to the right of this point and beneath the sternum, that
is, over the right ventricle, we sometimes observe that the
sounds differ in the two situations, both in strength and clearness.
In some cases I have also met differences in the pitch of the
sound.

“ Lastly, if we auscultate above the base of the heart, a little
above the middle of the sternum, at the right edge of this bone,
under which part the aorta runs, we will sometimes find the sounds
to differ in strength and clearness, and, in very rare cases, the

240

DISEASES OF THE VALVES OF THE HEART.

pitch also, from those which we hear on applying the stethoscope
at the same height, but about an inch to the left of the sternum.

“ The modifications of the sounds in the parts I have pointed
out, which are frequently perceptible in perfectly healthy indivi-
duals, arc much more evident when we examine those who suffer
from various morbid conditions of the heart. We should, therefore,
first look for these differences in persons labouring under affections
of the heart ; and when we have once become familiar with them,
we will also perceive the same in healthy individuals, in whom
they are much less striking.

“ If we have the opportunity of examining many patients in
whom the heart is morbidly affected, we will meet cases in which
neither first nor second sound is to be heard in the part of the
thorax against which the apex of the.lieart strikes, corresponding
to the left ventricle, in which cases we rather perceive in this si-
tuation a single or double bellows murmur, sawing, rasping, &c.,
while to the right of this point, corresponding to the right ventri-
cle, and above the base of the heart, over the aorta and pulmo-
nary artery, both sounds are plainly heard. In general, the
sounds in the three situations are not similar in strength and
clearness. In other cases, on the contrary, we have in the
left ventricle, in the aorta, and pulmonary artery, both sounds
frequently also differing from one another ; while over the
right ventricle nothing but a murmur is heard, which is syn-
chronous with the systole of the ventricles.

Cases are yet more frequently met with in which no [normal]
sound, but a single or double murmur, is perceived in the space
corresponding to the course of the aorta ; while both sounds are
distinctly audible over the right and left ventricle, and over the
pulmonary artery. It wfill also happen that we shall hear a single
or double murmur over the left ventricle, and over the aorta, while
we find both [normal] sounds persistent over the right ventricle
and pulmonary artery ; or we may hear murmurs over the left and
right ventricle, or over the right ventricle and the aorta, or over
the right and left ventricles and the aorta, and in the situations
where no murmurs exist, we may find in some cases the normal
sounds to be distinct, while in others they are indistinct or
wholly absent.

VIEWS OF SKODA.

241

« if these observations, made upon innumerable occasions, and
confirmed by others associated with me, be correct, — it appears
to follow, with tolerable certainty, that both ventricles, the pul-
monary artery and aorta, are capable, each separately, of pro-
ducing both the first and second sound perceptible in the region
of the heart.

“ The modifications of the sounds are frequently connected with va-
riations in the state of the valves of the heart, and we must, there-
fore, in explaining the sounds, take into consideration the action
of the valves during the motions of the heart.

“ If we compare a number of observations on living subjects
with the results of post-mortem examinations, we cannot avoid
the inference that the modifications of the sounds and mur-
murs are, in most cases at least, connected with the varying
. condition of the valves of the heart; for we generally find in a
patient in whom we have observed murmurs instead of [the nor-
mal] sounds, abnormal conditions of the valves ; excrescences,
thickening, diminution, narrowing of the openings, &c. Yet
it cannot be denied, that we sometimes find the valves in the
dead body not exactly in the normal state, although during life
i there was no modification in the sounds, or only such as might
possibly co-exist with a perfectly normal condition of the valves.

' Well-marked alterations in the sounds are not necessarily pro-
duced by every abnormal state of the valves; such changes may
occur only in certain abnormal conditions of the valves, or other
circumstances may co-operate with these conditions to produce
the change in the sounds.

“ It is by endeavouring to form a clear idea of what takes
place during the motions of the heart, in the valves, as well in
their normal as in their abnormal state, that we shall be able to
distinguish the conditions which may be considered as possibly
giving rise to the cardiac sounds, and as determining the modifi-
cations of these sounds and their change into murmurs. Through
such a review of these conditions we shall obtain a guide for our
observations, by means of which, or even by direct experiments,
we may be able to separate what is real from what is merely pos-
sible.

VOL. i.

242

DISEASES OF THE VALVES OF THE HEART.

“ Action of the bicuspid and tricuspid vcdves in the motions of the

heart.

“ Laennec maintained that the columnae carneae are so con-
nected with the valves that by their contraction they necessarily
open them. He was, consequently, also of opinion that the co-
lumnae carneae do not contract simultaneously with the rest of
the substance of the ventricles : that, on the contrary, their con-
traction ensues during the diastole of those cavities, so as to permit
the flow of the blood into them. Bouillaud, on the other hand,
considers it quite manifest that the valve is closed by the contrac-
tion of the columnae.

“ We may draw the columnae carneae, and with them the
chordae tendineae which spring from them, as strongly as we will
in the direction they follow in the heart, without closing the
valve, and the opening does not become smaller when the colum-
nae are placed more upon the stretch than when they are gently
drawn. The shortening of the columnae during their contraction
will, therefore, not effect the closing of the valve. We also do
not observe that in the relaxed state of the columnae the blood is
impeded in flowing from the auricles into the ventricles, and, con-
sequently, their function is neither what Laennec thought, nor what
Bouillaud supposed. Since the contraction of the columnae does
not determine the closing of the valve, no alternative remains but
that the stream of blood itself, by pressing against the valve, ef-
fects its closing. The use of the chordae tendineae, which pass
from the columnae to the valves, is evidently to prevent the in-
version of the latter, for, were the free borders of the bicuspid and
tricuspid valves not firmly held by the attachment of these tendi-
nous structures, the valves, during the systole of the ventricles,
would be driven by the stream of blood partly into the auricles,
partly towards the orifices of the arteries, and the closing of the
valves could not take place.

“ The chordae tendineae are distributed on the valves in a man-
ner which is of the highest importance to the function of these
valves, so much so, that without such an arrangement the bicus-
pid and tricuspid valves could not prevent the regurgitation of

ACTION OF THE AURltfULO-VENTRICULAR VAXVES. 243

the blood from the ventricles into the auricles during the ventri-
cular systole.

“ From each columna carnea several stronger cords run to
and are' inserted into the middle of the ventricular surface of the
valve, or some of them run to the base of the valve, and are in-
serted on the junction of the valve with the wall of the ventri-
cle. From these stronger cords, — at about their middle, — and
also from the columnas, arise weaker ones, which are inserted
somewhat nearer the free border of the valve. These latter
serve as points of attachment to still more delicate ones, which
are inserted nearer the free edge of the valve, and even on it.
No chordae tendineae are attached to the auricular surface of the
valve.

“ If we draw the columnse in the direction they follow in the
heart, we will see that this puts only the stronger cords, which
spring from the column® themselves, upon the stretch ; the weaker,
which do not take their origin from the column®, and are in-
serted near the free border of the valve, or on it, remain flac-
cid under the strongest traction. Consequently, we can never
extend the free border of the valve by so drawing the columnae
came®; this is extended merely from its point of attachment to
the point where the chordae tendineae springing from the colum-
nae are inserted. The entire remaining part of the valve, from the
free border to its middle portion, remains flaccid.

“When we press back any point of this flaccid portion in the
direction of the auricle, so that the cords which are attached
to the part become extended, we see on it a number of pouches ;
and if we examine the entire valve in this manner, we shall be
convinced that the ventricular surfaces of the bicuspid and tricus-
pid valves are not even, but exhibit pouches which begin imme-
diately at the free edge of the valves, extend to the middle of their
surfaces, or even further, and are manifestly formed in conse-
quence of the peculiar mode of insertion of the tendinous cords.

“ If we blow against the flaccid portion of the valve, towards
the auricle, it will become inflated like a sail, and we may in
this manner at once demonstrate the pouches in the entire circum-
ference of the free edge of the valve. The same occurs \yhen we
pour water against the valve.

r 2

244

DISEASES OF THE VALVES OF ME HEART.

“ When the blood endeavours, during the ventricular systole,
to regurgitate towards the auricle, it must necessarily catch in the
little semilunar pouches of the bicuspid and tricuspid valves, and
swell the flaccid portion of the valve opposite the auricle to as
great an extent as the chordae tendinea? which are inserted into it
will permit. By these distensions the passage to the auricle is
closed against the blood, if the valve be held by the cords in such
a direction that no opening shall remain after its distention.
Hence the situation of the insertions of the cords on the walls of
the ventricles, and their length, are not matters of indifference.

“ The capacity of the ventricles is very different at the com-
mencement of the systole from what it is at its termination, and
the insertions of the columna? carnea? during the progress of the
systole are drawn nearer and nearer to the attachment of the bi-
cuspid and tricuspid valves. In order that the length of the
chorda? tendinea? should be adapted to close the valve, it is evi-
dent that those cords whose function it is to hold the latter in a
proper direction must arise from such an arrangement as the co-
lumnas carneae.

“ Thus, did they spring directly from the walls of the heart,
they must, if their length were exactly right at the commence-
ment of the ventricular systole, during its progress become too
long, and, on the other hand, if they were only so long as to hold
the valve in the proper direction at the end of the systole, they
would obstruct the diastole. • Since a change in the length of the
chorda? tendinea? is impossible, they must necessarily be connected
with muscles, and the use of the columna? carnese is evidently to
keep the valve in the proper direction by their alternate contrac-
tion and extension. Thus during the progress of the systole the
columna? become shortened in proportion as their points of in-
sertion approach the attachments of the bicuspid and tricuspid
valves, an action which, were it not for the pressure of the blood,
woidd maintain the chorda? tendinea? in precisely the same degree
of tension they had at the commencement of the systole ; and this
tension would also continue unaltered during the diastole, in con-
sequence of the columna? becoming lengthened in proportion to
the separation of the walls of the heart from one another.

“ The correctness of the view here explained of the function

ACTION OF THE AURICULO-VENTRICULAR VALVES. 245

of the column® came® appears to me to be corroborated by the
fact, that the portion of the tricuspid valve situated on the sep-
tum receives its chord® tendine® only from very short columns,
or directly from the wall of the heart. The points of insertion of
these cords, in fact, approach the attachments of their portion of
the valve but little or not at all during the systole, and, of course,
are as little removed from them during the diastole. In this case
a tendinous cord is sufficient to retain the valve, since no change
in its length is necessary".

“ From what has been stated, the motions of the bicuspid and
tricuspid valves would appear to be as follow' : — During the contrac-
tion of the ventricles the valves are, by the shortening of the co-
lumn®, prevented from being drawn out of these cavities and from
approaching the mouths of the arteries. The column® and the
chord® tendine® arising from them are at the same time drawn
towards one another, and the surface of the valve to which the
cords are attached becomes folded, and the opening of the valve is
diminished.

“ The remaining opening is closed by the portion of the valve
which is not acted on by the shortening of the column®. This
closing is effected by this part of the valve becoming filled, like
a sail, with the blood which presses against it. The several points
of the free edge of the valve come reciprocally into contact, and
partly by the support they yield to one another, but principally
by means of the chord® tendine®, the turning over of the free
edge is prevented. As the delicate cords running to the free
edge arise from the stronger chord® tendine® springing from the
column® carne®, all the latter stronger cords are brought into a
curve by the action of the pressure of the blood against the in-
flated portion of the valve, which action is communicated by
the fine cords attached to them.

“ During the diastole of the ventricles the column® carne®
become lengthened and separated. The blood flowing from the
auricle would press the valve against the walls of the heart, and
partly towards the mouth of the artery, were it not retained by
the chord® tendine® in its proper position. The chord® tendi-

a “ The use of the columme carncte, as here laid down, lias already been described by
Professor Weber, in Ilildebrandt’s Anatomic.”

246

DISEASES OF THE VALVES OF THE HEART.

ne£e arising from the columnse carnece are, therefore, not relaxed
during the diastole of the ventricles; for were they so, the valve
might, at the beginning of the systole, not be in the direction re-
quired for instantaneous closing; a greater portion of the blood
would always regurgitate from the ventricle into the auricle, and
the valve should be drawn into its proper position, often against
the stream of blood, by the contraction of the columnas carnese.

“ In order that the bicuspid and tricuspid valves may perfectly
discharge their functions, it is necessary that their free edge shall
present the pouches I have described, and that the chordae tendi-
neaj and the columnae carnese shall have a length corresponding
to the capacity of the ventricles. If the conformation of the valve
be abnormal, it is either not in a condition to prevent the reflux
of the blood from the ventricle into the auricle during the ventri-
cular systole, that is to say, the valve is defective; or it opposes
the passage of the blood from the auricle into the ventricle during
the ventricular diastole.

“ The former condition takes place in thickening and shorten-
ing of the free edge of the valve, or in adhesion of the latter to the
chordae tendinese arising from the centre of the surface of the valve,
by which the pouches are destroyed ; in shortening or lengthening,
or rupture of the chordae tendinese, in the formation of excrescences,
the deposition of coagula on the edge of the valve, and in adhesion
of the surface of the valve to the wall of the ventricle ; the latter
condition, on the other hand, is produced by considerable excres-
cences, coagula of blood, or calcareous concretions, on the auricu-
lar surface of the valve, or by the adhesion of the chordae tendineae
to one another and to the free edge of the valve, preventing the
due action of the latter.

“ Action of the Semilunar Valves.

“ The semilunar valves of the aorta and pulmonary artery are,
as is well known, pressed by the blood which is impelled during
the ventricular systole into the artery, against the wall of this ves-
sel, but during the diastole they are again distended by the blood,
which is driven by the elasticity of the arteries forwards and back-
wards and towards the ventricles.

“ By excrescences, calcareous concretions, &c., developed on

ACTION OF THE SEMILUNAR VALVES.

247

the aortic valves, or by the adhesion of the three valves to one
another, the latter are sometimes rendered immovable and inca-
pable of being pressed against the wall of the artery, and they will
thus obstruct the entrance of the blood into this vessel. If the
; free border of these valves be shortened or turned over, or be the
seat of excrescences, if the valves be partially torn from their at-
tachments or be perforated, they will not be in a condition to
prevent the reflux of the blood, and the blood will, during the
ventricular diastole, flow back from the aorta into the left ven-
tricle. . .

“ Whether the aortic valves have closed during life is very

easily demonstrated in the dead body. If water be poured into
an aorta, the valves of which are in their normal state, the fluid
will not reach the left ventricle, but, being retained by the closed
valves, will remain in the aorta, while, if the valves be impel feet,
it will flow into the ventricle.

“ We possess no such test as to the state of the bicuspid and
tricuspid valves. If we open the left ventricle at the apex, and,
having tied the aorta, pour water through the opening, the passage
of the fluid into the auricle will sometimes be prevented by the
bicuspid valve. However, a repetition of the expenment will
convince us that we have obtained no information as to the state
of the valve. If we fill a ventricle with water, close its arterial
opening, and then compress the ventricle, the bicuspid or tricus-
pid valve certainly becomes distended, but does not, even when
its state is quite normal, completely prevent the reflux ol the wa-
ter. The reason of this is manifestly that the contraction of the
column® carne® and the multilateral diminution of the cavities of
the heart cannot be imitated. We can only judge in the dead
body whether the bicuspid or tricuspid valves have closed during
life from the conformation of the valves, of the chord® tendine®,
and of the column® carne®, and from the changes which defect
of those valves generally produces in the auricles.

“ Explanation of the Sounds in the Ventricles.

“ A comparison of observations on the living with the results
of post-mortem examinations shows that a distinct first sound is
rarely heard over the left ventricle when the bicuspid valve is

248 DISEASES OF THE VALVES OF THE HEART.

not in a condition to prevent the regurgitation of the blood into
the left auricle during the ventricular systole, i. e. when the bi-
cuspid valve is defective. In such a case we generally hear a mur-
mur synchronous with the systole, in the portion of the thorax
against which the apex of the heart beats, while in all other parts
of the cardiac region the first sound is plainly audible. The same
is true of the right ventricle when the tricuspid valve has become
defective. We then hear no distinct first sound over the right
ventricle, although it is perceptible in the left ventricle, the aorta,
and pulmonary artery, and in its stead we generally find a mur-
mur to exist.

“ The first sound in the ventricles, accordingly, generally
arises from the sudden interruption of the stream of blood towards
the auricle, in consequence of the dilatation of the bicuspid and
tricuspid valve; also from the striking of the blood against these
valves. Every impulse, as is well known, creates a sound, which
is duller in proportion to the softness of the striking or of the
stricken body. The tension suddenly effected in the valve by the
pressure of the blood undoubtedly contributes to the production
of the first sound ; for fibres and membranes, when suddenly
stretched, give rise to a sound, — not only in the air, as Gendlin
and others believe, — but also under water. The fact that the
first sound is often clear and clapping, and sometimes even ring-
ing, seems especially to indicate that the stretching of the valves
contributes to its production.

“ It is manifest, however, that the first sound may sometimes
also arise from the striking of the heart against the thorax. If in
the dead body we strike the inner surface of the thorax with the
finger, or with the apex of the heart somewhat firmly compressed,
a clinking, or a sound differing but little from the ordinary first
sound, will be heard through a stethoscope externally applied. If
a part of the wall of the heart be, during the ventricular diastole,
somewhat removed from the wall of the thorax, but during the
systole strike it again, or even if the heart during the systole strike
another part of the thorax than that against which it lies during
the diastole, a clinking must likewise be produced, or a sound
arise quite similar to the ordinary first sound of the heart; for
the substance of the heart becomes hard during the ventricular

CAUSE OF THE VENTRICULAR SOUND. •

249

systole. If the heart strike against the same portion of the thora-
cic wall on which it lies during the diastole, its impulse can pro-
duce either no sound or only a very dull one.

“ The muscular rustling of the heart never occurs as a clapping
; sound, but merely as a dull protracted one, which I could never,

; in accordance with the phraseology I have adopted, designate
; a ‘sound’ (ton), but must allude to as a noise approaching to the
1 ‘murmur.’ This might be expected, for no muscle ever gites
a defined, clapping, or ringing tone. I am not yet in a position
to state, from observations on living subjects, whether the con-
i traction of the substance of the heart is really attended by such
a sound. The cases attended with violent impulse of the heart,
and, consequently, with strong contraction of its substance, in
which no first sound is audible, are not rare.

“ The causes of the first sound now enumerated are not suffi-
cient for all cases ; all experiments particularly, hitherto made with
a view to explain the modifications of the first sound, have proved
imperfect.

“ Greater difficulties attend the explanation of the second
sound in the ventricles than of the first. It cannot be maintained
that in the normal condition of the heart the second sound is al-
ways produced in the ventricles, for it is often probable, and not
unfrequently certain, that the second sound heard over the heart
arises in the arteries, and can, on account of its intensity, be
heard at some distance. But there are certainly cases in which
we are compelled to admit that the origin of the second sound
is to be found in the region of the ventricle. Such are those
cases in which the second sound is nearly absent or feebly per-
ceptible over the base of the heart, while at the apex it is loud
and clear. It cannot be conceived that such a second sound in
the region of the apex is caused by the striking of the heart
against the wall of the thorax, for this does not take place during
the ventricular diastole.

“ Perhaps the striking of the blood against the walls of the
ventricle during the ventricular diastole may sometimes pro-
duce the second sound. In the left ventricle this impulse in
a defective state of the aortic valves, and in a defective , state of
the bicuspid valve, is undoubtedly strong. Yet I have only in

250

DISEASES OF THE VALVES OF THE HEART.

a single case, where the aortic valves were defective, found the
second sound stronger at the apex than in any other situation;
in this case it was certainly uncommonly strong and ringing. In
a defective state of the bicuspid valve an increased second sound
at the apex occurs more frequently.

“ In constriction of the left ostium venosum we sometimes
hear, instead of a protracted murmur with the diastole, two dull
sounds over the left ventricle. This phenomenon Gendrin uses
as the foundation of his explanation of the second sound of the
heart, deriving the double second sound from the non-contempo-
raneous filling of the two ventricles. To me it seems more likely
that the two sounds are part of a murmur which arises at the con-
stricted part ; that is to say, the murmur caused by the constric-
tion is divided, when the action of the heart is feeble, frequently
into two, but sometimes into three sounds. Further, in many
cases, the murmur cannot be distinctly heard at one point, while
around it two or three sounds, as it were the stronger periods of
the murmur, are heard.

“ Explanation of the Sounds in the Arteries.

“ In every large artery we can, in rare cases, hear a sound
contemporaneous with the pulsation, which exactly resembles the
sound of the heart. I do not think it can occur to any one to
explain sounds heard in the crural or brachial artery by transmis-
sion from the heart ; nor must we regard the sounds in the carotid
and subclavian otherwise than as produced by these arteries, when
there is either no sound perceptible in the cardiac region, or a
weaker one than that heard in the neck. The latter phenomenon,
especially, is frequently to be observed, but has generally been as-
cribed to a peculiar power of conducting sound, or has been left
entirely unexplained. That the sound will be variously trans-
mitted, according to the different condition of the thoracic vis-
cera, is indubitable. But we will find cases enough in which
the strength of the sounds above or below the clavicle, with
weakness of the same sounds in the cardiac region, cannot be ex-
plained by the power of conducting sound, because the lungs are
in a perfectly healthy condition. Bouillaud also ascribes a sound
to the arteries, which he, however, does not state to be similar to

EXPLANATION OF THE ARTERIAL SOUNDS. 251

a cardiac sound, but compares with the noise produced by the
fingers when we give ourselves a rap on the nose. Certainly, the
arteries distant from the heart give incomparably more frequently
a merely mute sound, such as Bouillaud describes ; the nearer
ones, on the contrary, the carotid, subclavian, aorta, and pulmo-
nary artery, give in general a sound as loud as those audible in
the cardiac region ; and, on the other hand, the sounds audible in
the cardiac region are likewise sometimes mute.

“ The sound audible in the arteries, synchronously with the
pulsations, may be explained by the suddenly increased tension
of the arterial coats. The second sound is audible in the aorta
and pulmonary artery, and generally also in the carotid and sub-
clavian. In the other arteries we rarely hear any sound coinci-
dent with their systole.

“ The second sound in the aorta and pulmonary artery evi-
dently arises from the shock of the column of blood contained in the
arteries against the semilunar valves after the ventricular systole.
The blood impelled by the systole into the elastic arteries is com-
pressed by them, and so soon as the impulse from the heart has
ceased, is necessarily driven rapidly back towards that organ.

“ The current of the blood towards the heart is suddenly arrested
by the semilunar valves. The shock which these suffer is com-
municated to the walls of the arteries, and not only is a sound
produced thereby in the aorta and pulmonary artery, but this
sound is also frequently heard in the carotid and subclavian, and,
indeed, even when the aorta has lost the condition necessary to
the production of a sound. This explanation of the second sound
in the pulmonary artery and aorta is placed beyond doubt by
observations on healthy and diseased subjects, and this sound ap-
pears to arise in no other way.

If the semilunar valves of the aorta have become defective, we
hear no second sound over the aorta, but instead of it a murmur;
the second sound continues, on the contrary, plainly audible over
the pulmonary artery. If the coats of the pulmonary artery are
abnormally distended, which must always be the case when the
circulation in the lungs is overloaded, the second sound will be
heard very much increased in strength over the pulmonary artery,
while over the aorta it may be weak, or inaudible, or replaced by

252

DISEASES OF THE VALVES OF THE HEART.

a murmur. The pulmonary artery, being strongly distended,
presses with greater force upon the blood contained in it, and the
shock of the column of blood against the semilunar valves is con-
sequently more violent.”

I have given the observations of Skoda in full, wishing to
avoid the risk of misinterpretation had I given but an abstract
of them. It will be seen that, in the general doctrine — that many
causes concur in producing the sounds of the heart — his views and
mine coincide. And although it is not yet proved that the ven-
tricles, aorta, and pulmonary artery, are each capable of producing
two sounds, yet there are grounds for such an opinion besides
those which Skoda has mentioned. I have long thought that the
double sounds in aneurism were difficult of explanation, unless
on the supposition that a single cavity might produce a double
sound; and we occasionally hear a perfect double sound in the
carotids, which appears to belong to them specially. To this
subject we shall return when we examine the diagnosis of
aneurism.

With reference to the improbability of the sounds in the bra-
chial or other distant arteries being conveyed from the heart, the
context appears to show that it is the double sound of the heart
rather than any murmur, to which Skoda alludes. I have already
shown, however, that a musical murmur, proceeding from disease
of the aortic orifice, may be transmitted into the most distant ves-
sels ; and it is difficult to deny that if a murmur, originating in
the very region of the valves, may be thus transmitted, that a
sound (the second sound of the heart) might not occasionally be
heard even in vessels more remote than the carotid or subclavian
arteries.

I have not, in enumerating the possible causes of sounds in
the heart, spoken of murmur produced by muscular contraction
itself. Yet there are good reasons for believing that such may
occasionally be produced. We often observe a peculiar sound
in the heart, which is probably a murmur produced by the con-
traction of muscular fibre under particular circumstances. We
find it during the period of recovery of the heart in cases of ty-
phoid softening, especially in those instances where the first sound
has at one time been extinct, when it gives a peculiar prolonga-

SOUNDS OF MUSCULAR CONTRACTION..

253

tion of the first sound, which has some resemblance to valvular
murmur. We must, however, conclude, that it is a muscular mur-
mur, not only from its acoustic character, but from its speedy
■ subsidence as the heart’s impulse is re-established, and the ex-
i treme rarity of valvular murmurs in typhus fever.

Skoda believes that the sudden contraction of the cavities has
i no part in producing the sounds of the heart. Where so many
, causes seem to concur in producing the first, if not both the
sounds, it is difficult to prove that the ventricular contraction
produces any part of the defined and suddenly produced systolic
: sound. Yet we cannot agree with him when he declares that
bi i muscular contraction never gives rise to a clear and defined sound.
I have long been in the habit of exhibiting a simple mode of pro-
ducing sounds in the voluntary muscles, very similar to those of
the heart. If we insert a needle into a thick mass of muscle, such

Ias the calf of the leg, and, having introduced another into any
portion of the thigh, connect the two by bringing 'them into the
current of a small galvanic battery, we find that the gastrocnemii
muscles are thrown into clonic spasms, which continue for many
: seconds after the current has been interrupted. If during this

I period we apply the stethoscope, we hear not only the continuous
though confused muscular sounds, but often well-defined sounds,
which have characters singularly resembling those of the heart.
If, then, under excitement, a solid muscle is capable of giving de-
fined and sudden sounds, there seems no reason why similar re-
: suits should not arise from the contraction of a hollow muscle,

; such as the ventricle.

But further: we find that in the cases already described, of
disappearance of a valvular murmur consequent on the advance
N of mitral contraction, the cessation of the murmur is not attended
by loss of the first sound. On the contrary, the heart, as it
were, regains the first sound, which for a time had been merged
in the valvular murmur. It is then probable, that the valvular
: sound having been eliminated, the great source of the systolic
sound is the contraction of the left ventricle.

Finally. There is a form of morbid muscular action not de-
scribed by Skoda, in which the voluntary muscles are liable to
extraordinary and sudden contractions, so abrupt and well defined

254

DISEASES OF THE VALVES OF THE HEART.

as to produce a succession of sharp and distinctly marked sounds
of singular intensity. Minor degrees of this disease are not un-
common. Thus we find the phenomena in question on examin-
ing with the stethoscope the supra-spinous and acromial regions
in young persons, in which a nervous condition simulates phthisis,
and the rustling sounds thus produced are often mistaken for tu-
berculous rales. But in a case which I have frequently examined,
the patient, a young man, can at will produce a succession of
sounds from the left shoulder, so loud and sharp that they may be
compared to the sounds of squibs or the cracking of a whip.
When the ear is placed on the shoulder, the sharpness of the
sounds becomes painful. He has also the power of producing
sounds, evidently of the same nature, at the epigastrium and along
the insertion of the left ala of the diaphragm.

All these facts make it probable that muscular action may
have, occasionally at least, some part in the production, if not of
both sounds of the heart, at least of the first sound.

255

CHAPTER III.

DISEASES OF THE MUSCULAR STRUCTURES OF THE HEART.

The parietes of the heart are probably liable to all the vital
and organic changes observed in muscular structures. They may
exhibit hypertrophy or atrophy, fatty degeneration, and hetero-
logous deposits, or become the seat of changes which are secondary
to various essential diseases, but especially typhus fever. Their
functional diseases, also, seem analagous to those of muscles in
general, as we observe augmented or diminished contractility,
irregular action, and even a spastic state.

Further, we find that a weakened or paralysed condition
is produced by the effects of irritation of structures with which
they are in connexion ; this, as has been already noticed, may
be the cause of death in pericarditis ; and there appear reasons
for believing that a purely nervous paralysis may affect one or
more of the cavities of the heart.

Again, the muscles of the heart may be the seat of inflam-
mation (myocarditis), and although this condition is rare, it is
probably more frequent than inflammation of the voluntary mus-
cles.

It is still to be determined whether the cavities of the heart
are liable to change from mechanical causes alone ; whether dila-
tation, for example, is a purely mechanical result of obstruction to
the exit of the blood, or whether for its production in valvular
disease there is required not only obstruction, but a weakened
condition of the heart.

As the symptoms of valvular diseases are really those of alte-
rations of the cavities of the heart, we may now properly ex-
amine the latter class of affections, premising that although di-
latation and hypertrophy so frequently co-exist with alterations
of the valves, yet that they occur either as independent affec-
tions, or with an amount of valvular disease so insignificant as to
constitute an accidental and unnecessary complication ; we must,

256 DISEASES OF THE MUSCULAR STRUCTURES OF THE HEART.

however, note a class of cases which, with the symptoms of dila-
tation, present the acoustic signs of valvular lesion, arising not
from disease of the valves themselves, but from this, that the en-
largement of the orifices renders the valves inadequate. Of this
the case already given (see page 168) is an example ; such a condi-
tion is more likely to occur in the case of dilatation without
hypertrophy, for in the latter case the valves themselves become
extended and enlarged, partaking, as it were, in the general in-
crease of the heart11.

a To determine the existence of dilatation or hypertrophy of the heart on dissec-
tion is often a matter of great difficulty to physicians, a circumstance not to be wondered
at when it is considered that so few have examined the actual or normal dimensions of
the organ. Among the investigators who have taken up this subject, the first place
must be given to Bizot, whose measurements of the heart, under the various circum-
stances of age, sex, and disease, are more numerous, and probably more accurate

than those of any preceding observer. His Memoir, entitled Jlecherches stir le Canir

et le Systbne Arteriel clicz I'homme , par J. Bizot (de Gendve ), Menioires de la Socicte
Medicale d'observaiion de Paris, 1836) illustrates the value of the numerical method in
determining questions of normal and pathological anatomy. The following mode was
adopted in measuring the heart : — the breadth at the base was measured near to the union
of the auricles and ventricles, while the length was represented by a line arising at the
apex of the organ, and falling perpendicularly on its base. The thickness was also as-
certained ; the left ventricle was then opened by an incision along the rounded margin
of the heart from the apex to the base, and prolonged to the aortic orifice ; and, in order
to convert the ventricle into a plane surface, the auriculo-ventricular orifice was divided.
The length of the line passing by the convex and adherent margins of the sigmoid

valves, and terminating at the two incised edges of the wall of the ventricle, gave the

circumference of the base of the ventricular cavity ; and a second line, drawn from the
summit of the cavity and falling at right angles on the first, measured its height. In
measuring the thickness, three points were taken, namely : 1. Towards the base, at six
lines from the origin of the fleshy fibres. 2. At the point of greatest thickness, which is
found near the union of the lower to the middle third of the ventricle, measuring from
the base. 3. At a point four lines above the apex of the heart. The same points were
chosen for the measurement of the septum. The right ventricle was measured as follows :
it was divided from the base to the apex on its posterior portion, following the line of
union with the inter- ventricular septum ; another incision was made at its anterior surface,
starting from the pulmonary artery, and following the line of the septum. The ventricle
was thus divided into two portions, one belonging properly to it, the other constituted
by the ventricular face of the septum. The different measurements were made as in
the case of the left ventricle, care being taken to add the measurements of the two sepa-
rate portions ; and, avoiding in the measurement of the base to include the extent of the
auriculo-ventricular orifice, and that of the pulmonary artery. The thickness was taken
in the same way as in the left ventricle. M. Bizot has not published the measure-
ments of the auricles ; the dimensions of the arterial openings were ascertained by taking

DILATATION OF THE HEART.

257

DILATATION OF THE HEART.

The occurrence of an uncomplicated dilatation of the heart
must be considered as one of extreme rarity. In most instances
dilatation of the cavities is met with under two conditions : —

1. In connexion with valvular disease.

their circumference at the free border of the sigmoid valves and those of the auriculo- ven-
tricular openings along the line of adhesion of the mitral and of the tricuspid valves ;
finally, the arteries, having been divided so as to form a plane surface, were measured at
their origins, at their middle portions, and at their terminations. These researches were
made upon 157 subjects, of all sexes, every possible care being taken to avoid error ; the
dimensions of the entire heart and its different portions being statistically studied accord-
ing to age, sex, the height of the individual, and, finally, under the influence of disease.

These investigations were all conducted according to the numerical method of Louis,
a method which, whatever may be its dangers and difficulties as applied to the determi-
nation of the value of remedial measures, is admirably adapted for the settlement of many
questions of normal and pathological anatomy ; yet even in this latter department we can-
not join with many advocates of the system in decrying the value of preceding inves-
tigations because they were not based on the numerical method ; such a course, in fact,
is to ignore the labours of all those investigators whose works, from the sixteenth century
down, have made medicine a science. To the illustrious author of the numerical method
these observations will not, of course, apply ; yet the history of every doctrine shows us
that the reputation of the master may be compromised by the zeal of ardent but inexpe-
rienced disciples.

The following measurements, taken from the memoir of Bizot, are given by Hasse.
But as in the translation of his book by Dr. Swaine the French measures are adhered to,
it became desirable that the Parisian inch and line should be reduced to the English stan-
dard. My friend Dr. Moore has kindly furnished me with the following Table, in which
Bizot’s results are expressed in English measures.

In subjects between the thirtieth and forty-ninth year, the heart presents (according
i to Bizot) : —

English inches. English inches.

IN MEN.

IN WOMEN.

A length of

3.8299

3.6473

Breadth,

4.2430

3.9104

Depth,

1.2563

Length of left ventricle,

2.6176

2.8363

Breadth of ditto,

4.1056

Length of right ventricle,

3.3357

2.9731

Breadth of ditto,

7.4090

6.8047

Thickness of the walls of the left ventricle at the
base,

0.4324

0.3650

Do. at the middle,

0.4520

0.3936

Do. near the apex,

0.3165

0.2861

VOL. I.

258 DISEASES OF THE MUSCULAR STRUCTURES OF THE HEART.

2. As one of a group of lesions, in which organic and func-
tional disease of the heart, lungs, liver, and kidneys co-exist.
There is an asthenic and often a gouty condition of the system.
So great is the frequency of cases which may be placed in this
category, that we shall devote some space to their considera-
tion.

The leading characters of a large number of cases of dilatation
of the heart are as follow : —

1. Organic change of the valves is rare, and when met with
it is inconstant in its seat, nature, and amount, and incompetent
to explain either the symptoms or the condition of the heart.

2. There may be from dilatation of the ventricles such an
enlargement of the orifices as that the valves become incompe-
tent to close the openings. It is to be doubted whether in cases
of this kind we see the actual extension and enlargement of the
auriculo-ventricular valves, which are frequently observed in di-
latation with hypertrophy of the heart.

3. The parietes of the heart are thinned, and in many cases
loaded with fat. In some, too, the substance of the organ is in
an early stage of fatty degeneration11.

4. This disease is commonly met with in connexion with chro-
nic bronchitis, and the patient is liable to attacks of cardiac
asthma. Hepatic congestion, also, is common, and we may fre-
quently observe varying enlargement of the liver corresponding to
each attack of pulmonary congestion.

5. This disease, which frequently terminates in general dropsy,

English inches. English inches.

IN MEN. IN WOMEN.

Thickness of the septum of the ventricles at the

middle, 0.4362 0.3913

Thickness of the walls of the right ventricle at the

base, 0.1640 0.1512

Do. at the middle, 0.1158 0.1101

Do. near the apex, 0.0868 0.0822

Width of the left auriculo-ventricular orifice, . . 4.2987 3.6100

Do. of the right, 4.8145 4.1867

Width of the origin ofthe aorta (above the valves), 2.7412 2.4962

Do. of the pulmonary artery, 2.7991 2.6047

» The researches of Drs. Paget and Ormerod should be consulted on this subject. —
London Medical Gazette.

DILATATION OF THK HEART.

259

is often met with in connexion with a gouty habit in persons
advanced in life, and whose systems have been exhausted by over-
fatigue or undue depletion.

The leading characteristics of this afteetion are those which
indicate a weakened condition of the heart. The pulse is perma-
nently irregular, unequal, weak, and generally small ; and the pa-
tient suffers from dyspnoea, with occasional attacks of orthopnoea,
which are commonly induced by cold or fatigue, or are ushered in
by diminished secretion from the kidneys. It is under these cir-
cumstances that the already enlarged liver exhibits a rapid in-
crease of tumefaction, in a few hours descending far into the
abdomen, yet on the subsidence of the attack returning to its
ordinary volume, when it may be felt as a flat and indolent tu-
mour extending for an inch or more below the false ribs. This
phenomenon has probably a double origin, and may arise from
the combined effects of enlargement and of displacement. I he
enlargement is caused by the distention of the hepatic veins, and
the displacement by the tumefaction of the lung, which, as it
is generally emphysematous, is so distended at each new attack as
to produce an excentric displacement of the ribs, mediastinum, and
diaphragm, but resumes its former dimensions when the parox-
ysm has subsided11.

The physical signs observed in this affection are exactly those

0 The idea of Serres, that disease in man not only repeats the embryonic state of the
viscera, but may actually reproduce the normal state of organs in the lower animals
(“Recherches d’Anatomie Transcendente et Pathologique par M. Serres;” Paris, 1833),
may be referred to in considering this condition of the liver. On the great doctrine of
Serres, that pathological anatomy is not a science of exceptions, which is after all the
same as that of Broussais, though expressed in different words (see his “ Commentaires
sur les Propositions de la Pathologie”), I have already expressed my opinion in a re-
view of Serres’s work in the Dublin Medical Journal, first series, vols. ii. and iii.
But the close analogy between the condition of the liver with which we are now occupied
and that of the diving animals is very remarkable. On this subject Professor R. W. Smith
has the following observations, with reference to the case of Mr. Colles, in which the va-
rying enlargement of the liver was a prominent symptom : —

“ This interesting phenomenon was long since observed by Andral, in oases of cardiac
disease, obstructing the course of the venous blood in the lungs, and it affords another
proof that the functions of the liver are supplemental to those of the lungs ; the evidences
of this fact derived from observing the condition of the foetal liver, before the lungs are called
into action, its state in animals with vesicular lungs, incapable of aerating and decarbo-
nizing the blood perfectly, as well as in examples of open foramen ovale, are so well known

S 2

2G0 DISEASES OF THE MUSCULAR STRUCTURES OF THE HEART.

which would result from weakness and dilatation of the heart;
but it is to be noted that our experience of these cases is drawn
from studying the disease when complicated with affections of the
lung and liver. No case of simple dilatation has been observed
by me, but I am not disposed to deny the possibility of such an
occurrence.

There is a great similarity in the physical signs in these cases.
We observe that the sounds of the heart are often so affected as
to make it difficult to distinguish between the first and second,
a difficulty increased by their shortness and the irregularity and
rapidity of the action of the heart. Indeed, it is frequently no
easy matter to analyze the action of the organ ; generally, the
sounds are louder in the lower sternal than in the mammary re-
gion, and this condition, which represents the permanent state of
the heart, is aggravated in all its characters during each of the pa-
roxysms of dyspnoea to which these patients are liable. At such
times the impulse of the heart is often increased. It is stated by

to physiologists that it is unnecessary to do more than refer to them. The phenomenon
in question is, however, best elucidated by the observations made by the late Dr. Hous-
ton, on the circulating organs in diving animals ; he has shown, that in animals which
are capable of bearing submersion for a long period, as diving birds, the porpoise, the
seal, the otter, &c., the veins connected with the liver are dilated into enormous reservoirs,
which serve as a temporary resting-place for the blood, when stopped in its free course,
during the obstruction to respiration which occurs in the act of diving ; and this provision
or reservoir is much enlarged, and most generally extended throughout the venous sys-
tem of the body, in those animals which are capable of enduring submersion for the longest
period : in the others, whose submersion is only occasional, and that but for a short pe-
riod at a time, when diving for their prey in shallow, inland water, the hepatic veins
alone are dilated into receptacles for the blood retarded in its course; but in the seal and
in the porpoise, who frequent deep waters, and whose submersion is more prolonged, the
provision of a reservoir is extended throughout the greater part of the venous system of
the body. These ingenious observations of Dr. Houston appear to me to admit of being
legitimately made use of to explain tbe occurrence of the occasional and temporary en-
largement of the liver, in cases such as that under consideration ; they serve to prove that
it is a means of diminishing the dangers arising from pulmonary congestion, and a pro-
vision for retarding the circulation of venous blood through the system, while respiration is
seriously obstructed, and the lungs incapable of asrating the blood so as to maintain life.
In conclusion, I have only to observe, that the bilious tinge of the skin and the formation
of gall-stones in this interesting case are most probably to bo referred to the obstruction
of the pulmonary circulation. The observations of Tiedemann and Gtnelin tend to prove
that, in such cases, the secretion of bile becomes more abundant.” — Reports of the Patho-
logical Society , 1843.

DILATATION OF THE HEART.

261

authors that no praecordial fulness exists in this disease; but while
we admit this statement, we cannot hold that the want of praecor-
dial fulness is a diagnostic between this affection and dilatation
with hypertrophy, inasmuch as in the latter disease this physical
sign is often wanting.

As a general rule, we do not observe valvular murmur in this
affection, at least it rarely occurs in the special case under consi-
deration; yet we are not justified in declaring that simple dilata-
tion is never attended by murmur; nor, again, that where murmur
does exist, it is to be attributed, as Dr. Walshe believes, to an
enlargement of the orifices consequent on the dilatation of the
cavities. I have observed in a case of this kind that the mur-
mur which existed in the earlier periods of the disease disap-
peared during the last years of the patient’s life. This murmur
had the usual characters of a mitral murmur, and dissection af-
forded no explanation either of its appearance or disappearance.

There is not only a great similarity in the symptoms and signs
of this combination of diseases, but also in the mode of death.
Each attack or paroxysm, as it were, places the patient in a worse
position, until at length the lungs become congested, and death
by asphyxia closes the scene. In the case of Mr. Colies, extensive
solidiGcation of the lungs took place shortly before death, attended
with bronchial respiration and dry friction sound. Yet the ap-
pearances on dissection were rather those of splenization than of
hepatization8.

Although these cases are to be met with every day, especially
in private practice, we still observe that physicians differ as to their
nature. One holds that the liver is the organ in fault; another,
that the disease is in the valves of the heart; a third believes that
the symptoms are those of hydrothorax, from disease of the kid-
ney ; while a fourth sees nothing but misplaced gout. Each of
them maybe said to be in one sense right, all of them in another
sense wrong. That the heart, liver and lung are in fault, in
most of these cases, is certain ; that the kidney is functionally
affected, and the gouty condition present, is commonly true.

* Observations on the Case of the late Abraham Colics, M. D., &c. By William.
Stokes, M. D. Dublin Quarterly Journal of Medical Science, vol. i. p. 303.

262 DISEASES OF THE MUSCULAR STRUCTURES OF THE HEART.

But we must learn to look fairly at the entire case, and not
dwell on its separate phenomena.

In a clinical point of view these cases form one of a group of
diseases which may he classed as examples of weakness of the heart.
For although they differ in their special signs and symptoms, and,
above all, in their history and accompanying circumstances, yet
they agree in exhibiting a diminished force, especially of the ven-
tricles.

In the case of hepatic complication we observe that mercurial ac-
tion produces a singularly beneficial effect. This is not easy to ex-
plain. We do not know in many of these cases whether the he-
patic or cardiac disorder has had the initiative. This much is
certain, that, the combined disease being once established, a mu-
tual re-action takes place between the heart and the liver, so
that whatever influences one of these organs will produce a new
disturbance in the other.

As an illustration of what has been now said on this form of
disease of the heart, which, of the examples of dilatation, is unques-
tionably the most frequent, I will give the case of my venerated
friend and teacher, the late Mr. Colies, who so long filled the Chair
of Surgery in the Royal College of Surgeons in Ireland. The case
of this remarkable man and eminent surgeon was published by me
in 1844, but I believe that in inserting it in this work, though
in an abridged form, I shall be acting in accordance with the
expressed desire of Mr. Colies, that the history of his case should
be, as far as possible, made available for the advancement of me-
dicine.

Mr. Colles, as he advanced in life, experienced frequent at-
tacks of gout in its ordinary form, and from about the year 1834
was the subject of a chronic bronchitis, with occasional exacerba-
tions of the disease in an acute form. During these attacks the
prominent symptoms were dyspnoea and palpitation, and the treat-
ment adopted was to employ small general bleedings, followed by
the use of blue pill and Dover’s powder. He was occasionally
liable to erysipelas of the face in a mild form, and it was found
that both the erysipelatous and gouty attacks were attended with
a suspension or diminution ot the affection of the chest.

In this state of health Mr. Colles continued for about six yeais,

DILATATION OF THE HEART.

263

during which time he hardly ever intermitted those laborious du-
ties which all who rise to eminence in the profession of medi-
cine must undertake, and bear as they best may. In the spring
of 1840, however, the first symptoms of a yielding of the system
took place, and in a sudden manner. Mr. Colies had retired to
bed, feeling as well as usual, but during the night was seized with
a paroxysm of cardiac asthma. He described the sensation of
impending suffocation at the commencement of the attack as be-
ing dreadful. He remained in a state of orthopnoea during the
night, with wheezing respiration. In the morning the pulse was
rapid, irregular, and unequal,— a condition to which the action of
the heart corresponded. The chest was clear on percussion. A
fit of gout in the lower extremities soon supervened, but on its
disappearance the legs remained unusually oedematous.

At this period of his case the heart presented the following
physical signs The impulse was feeble, irregular, and rapid, and
the organ seemed to impinge over a large surface. So irregular
and rapid was the action of the heart, that the analysis of the
sounds was a matter of great difficulty, the first occasionally resem-
bling the second sound, and vice versa. There was no valvular
murmur, nor any unusual pulsation or thrill in the arteries.

A few months having elapsed, Mr. Colles was recommended
to try the effect of change of air and travel, with the double view
of obtaining some advantage from the effects of a new climate,
and the benefit of rest from his professional exertions. He pro-
ceeded to Switzerland, where his health was so greatly improved
that on one occasion he found himself able to walk up hill for a
considerable distance. This restoration of his former powers of
exertion afforded him great happiness. Some time, however, af-
ter his return to Dublin, his old attacks returned. I saw him after
an interval of several months, and for the first time observed that
the liver was permanently enlarged, forming a smooth, flat tumour.
He continued to suffer, from time to time, from paroxysms of
dyspnoea, which were generally preceded by diminution in the se-
cretion of the kidneys. During these attacks, which generally
lasted for several days, the irregularity of the heart and the prae-
cordial distress increased, until orthopnoea was established. The
kidneys acted scantily, and no copious sediment appealed in the

2G4 diseases of the muscular structures of the heart.

urine. On each attack the tumefaction of the liver increased with
gicat lapidity, but this condition as rapidly subsided with the im-
provement in the symptoms. No relief was ever obtained until a
free action of the kidneys was established; but it was found that
this could only be effected by the use of mercury followed by diu-
retics. On several occasions the diuretic treatment, not preceded
by mercury, was tried, but it always failed, so that the number of
times in which a distinct course of mercury was employed was
very great. To this remedy, in a great degree, must the prolon-
gation of Mr. Colles s life be attributed : for, on various occasions,
the symptoms had gone so far as to cause complete orthopnoea,
with unusual anasarca, and alarming pulmonary congestion.

In this condition of intervals of comparatively good health,
while the attack came on once in about every five weeks, Mr. Col-
les continued till the summer of 1843, when, after a mild course of
mercury, continued for many weeks, Mr. Colies regained a state
of health to which he had been long a stranger. His appearance
improved, he even gained flesh, and had an excellent appetite.
Another bad attack supervened in the early part of the autumn, but
it yielded to the usual treatment. But this was the last time that
the system responded to medicine. In October a new invasion
of the disease set in, having precisely the characters of the former
attacks; and for the first time the mercurial treatment failed. The
anasarca increased, and the occurrence of a congestion of both
lungs, so great as to cause general dulness and bronchial respira-
tion, was the immediate forerunner of death, which took place on
the 1st of December, 1843a.

a Were I the biographer of Mr. Colies, I might enlarge on the many excellent quali-
ties of his mind, on the independence of his character, his boldness of thought, his warmth
and largeness of heart, and his unquenchable zeal in the practice and the teaching of his
profession. It is only when we lose a great possession that we are able to estimate its
full value. But it is a privilege allowed to the good and wise, that their example, which
in one sense is their spirit, remains after them. Clear in his convictions as to what was
right, and steadfast to do and to teach only that which he thought was right, Mr. Colles
gave to Irish surgery a great impetus, and a lustre which it cannot lose. From an early
period of the illness which terminated his existence, Mr. Colles was in the habit of speak-
ing calmly and freely on its nature to me and his other medical friends, and of giving his
views as to its probable termination. So far back as the summer of 1842 he observed
to me that a time must soon arrive when those remedies which had so often succeeded
must fail ; and he directed that a careful examination of his remains should be made

DILATATION OF THE HEART.

265

The examination of the body was made by Professor R. W.
Smith, in the presence of Sir Henry Marsh, Professor Harrison,
and myself.

“ The surface of the body generally was cedematous, but the
swelling was greatest in the hands and feet ; the skin was slightly
tinged with jaundice. On opening the cavity of the thorax, it was
observed that the costal cartilages had been converted into bone :
when the sternum was removed the sac of the right pleura was
found to contain about lialf-a-pint of dark-coloured serum, in
which were suspended numerous flakes of lymph, which appeared
to have been recently effused ; the right lung was, throughout its
whole extent, in a state of extreme congestion, and at its base was
expanded into two large globular tumours, each about the size of
an orange, heavy and dark-coloured, though obviously of an em-
physematous character; when divided through their centre, they
were found to contain not only air, but also a considerable quan-
tity of dark blood, of a venous character, producing an appearance
very like that of the interior of the spleen. When the blood was
washed away the surface of the section presented a highly vesicu-
lar aspect; the cells were large and very irregular. The entire
of this congested lung, with the exception of a small portion at
the apex, was more or less solid, but did not present any of the
characters which distinguish solidification, the result of pneumo-
nia; it did not break down under moderate pressure; the solid
feel which it possessed arose from its extremely congested state.

by Professor Smith, in the presence of his medical attendants. “ I think,” he said to
me, “ that this examination will add to our knowledge, and I know that the dissection
will be made with accuracy and the result he truly given.” He subsequently wrote the
following letter to Professor Harrison : —

“ October 22, 1842.

“My dear Robert, — I think it may he of some benefit, not only to my own family
hut to society at large, to ascertain by examination the exact seat and nature of my last
disease. I am sure you will grant my request, that you will see that this be carefully and
early done. The parts to which I would direct particular attention are the heart and the
lungs, a small hernia immediately above the umbilicus, and the swelling in the right hv-
pochondrium.

“ From the similarity of the Rev. P. Roe’s case with mine, I suspect that there is some
connexion between this swelling of the hypochondrium and the diseased state of the heart.

“ Yours truly, dear Robert,

“A. C’OLUis.”

266 DISEASES OF THE MUSCULAR STRUCTURES OF THE HEART.

“ The sac of the left pleura was obliterated throughout its
whole extent by organized, adhesions, which were evidently of
very long, duration ; the left side of the chest was contracted ; the
lung, smaller than natural, gorged with blood, and sunk back to-
wards the spine, yielded to and broke down under a very gentle
pressure: it presented a purplish red colour, did not crepitate any-
where, and resembled closely the appearance of the spleen, when
under the influence of decomposition ; the bronchial glands, in the
posterior mediastinum, were enlarged, and contained calcareous
matter. There was no effusion into the sac of the pericardium,
nor any adhesion between its opposed surfaces. The heart was
much larger than natural, but not proportion ably increased in
weight: its left cavities were collapsed and flaccid, while those of
the right side were distended with dark blood, especially the
auricle. The surface of the organ was of a pale brown colour ;
the quantity of fat upon it was much greater than natural ; its
muscular tissue, pale, soft, and greasy, was easily ruptured. The
left ventricle did not contain any blood ; its cavity was remark-
ably large, but there was no hypertrophy of its parietes ; it pre-
sented an example of great passive dilatation ; the left auricle
was also empty; the auriculo-ventricular openings were natural;
and the same may be said of the aortic orifice — at the attached
margin of one of the valves there was a small particle of calca-
reous matter ; it was not as large as the head of an ordinary-sized
pin, and in no way interfered with the due exercise of the func-
tions of the valve; water poured into the cavity of the aorta did
not enter the ventricle ; the lining membrane of the aorta was
stained of a deep red colour, and several atheromatous depositions
were observed beneath it; numerous globules of oil were seen
floating upon the surface of the blood, which collected in the
chest during the examination of the heart. The sac of the peri-
toneum contained about a quart of fluid ; the liver, though not
much enlarged, extended below the margin of the ribs ; it was of
an exceedingly dark mahogany colour, presented a tumid and
swollen aspect, and a rough and granular surface. When a sec-
tion was made through it, the dilated veins poured out copious
streams of exceedingly dark blood; the gall-bladder contained
thirty moderate-sized gallstones. Upon the right side of the um-

DILATATION OF THE HEART.

267

bilious there existed traces of a small hernia, which Mr. Colles
had requested might be examined ; when a section was made
through the kidney, globules of oil flowed with the blood ; the re-
mainder of the urinary apparatus and the prostate gland were
quite healthy”11.

Let us now take a general view of the symptoms in these
cases. They are commonly held to proceed from contraction of
the mitral orifice. At first sight it would appear a matter of lit-
tle consequence, as to whether the disease was a valvular affection,
or was seated in the muscular apparatus. Yet great errors in prac-
tice may result from an erroneous view of the case being taken.
The patient is forbidden stimulants to which he has, perhaps,
been accustomed. He is put on a spare diet, digitalis is used, and
all active exertion inhibited from the fear of its causing sudden
death, an apprehension which, when conveyed to the patient’s
mind, produces the worst effects.

This disease presents itself in a twofold aspect, namely, in its
stages of quiescence and of paroxysmal aggravation.

In the intervals of the exacerbations we may find our patient,
to all external appearance, in a good state of health. He eats,
drinks, and sleeps well, and not unfrequently is able to fulfil his
ordinary avocations in life, so far as these can Ije performed with-
out great muscular effort. If he be a professional or mercantile
man, he can attend effectively to his duties. His head is clear,
and his nervous energies unaffected. He may have a slight de-
gree of oedema of the lower extremities, and a chronic cough, but
this is attributed to gout, and to an habitual bronchitis. We find,
however, that his powers of ascending any elevation are much
diminished, and his physician observes that the pulse is perma-
nently small, weak, irregular, and intermitting; and if an exa-
mination of the abdomen be made with care, the liver can be felt
flat and extending considerably below the margin of the ribs ;
yet the patient feels in good health, he has no jaundice, and is
able to enjoy society.

The exacerbation generally comes on in connexion with an
increase of the bronchial affection, till severe orthopnoea is in-

* Dublin Quarterly Journal of Medical Science, First Series, vol. i. 1846.

268 DISEASES OF THE MUSCULAR STRUCTURES OF THE HEART.

duced, and it begins with diminution of the renal secretion, fol-
lowed by the most extreme cardiac and pulmonary suffering.

The dyspnoea and diminution of urine are the principal symp-
toms. One or two dreadful paroxysms of cardiac asthma may
occur, while at intervals an apparently increasing bronchial effu-
sion threatens the life of the patient. The suppression of urine
is extremely rapid, so that in two or three days the kidneys se-
crete but a few ounces of fluid. The patient is tormented by the
difficulty of breathing and the apprehension of approaching death,
and the pulse becomes more rapid, more feeble, and irregular,
while the action of the heart is such as almost to defy any stetho-
scopic analysis. The rhythm is altogether disturbed, and a pro-
tracted observation is necessary to determine which is the first
and which the second sound of the heart. The respiration is la-
borious, wheezing, or even rattling ; the chest sounds clear on per-
cussion, but extensive sonoro-mucous rattle is largely developed,
while the signs of congestion, or even oedema, of the pulmonary
structure are commonly to be observed in the postero-inferior por-
tions of both lungs. No signs, however, of liquid effusion into any
of the serous cavities are discoverable, though the patient presents
all the symptoms of hydrothorax as laid down in nosological
works.

The hepatic complication is of great importance, and presents
some singularly striking phenomena. Without fever or gastro-
intestinal inflammation, the liver is observed to enlarge often
to such an extent that the tumour may advauce below the um-
bilicus. This augmentation occurs with great rapidity, but is
unattended with any signs or symptoms of hepatic inflammation,
and it subsides to a greater or less degree when the state of pa-
roxysmal suffering has been subdued. Andral has noticed this
singular augmentation of the liver, which is often as remarkable
and recognisable as that of the enlargement of the spleen in ague.
The tumour is flat, and either painless on pressure or very slightly
tender. With each paroxysm of the disease the hepatic tumour
seems to gain a slight permanent increase ; but the alternation of its
enlargement and diminution, corresponding to each attack of the
disease, forces the idea on the mind of the observer that the organ,
is in an erectile condition.

DILATATION OF THE HEART.

269

One of the most remarkable circumstances in this curious com-
bination of symptoms is the suppression of the renal secretion, and
the subsidence of at least the aggravated symptoms of the attack
on its restoration. There is no reason whatever to believe that
the kidney is the seat of organic disease.

It is difficult or impossible, in the present state of our anato-
mical knowledge, to explain the phenomena of this disease. The
morbid state of the heart, consisting in its weakness, dilatation,
and irregular action, and the permanently enlarged, though in-
dolent condition of the liver, may be taken as the constant cha-
racteristics, while the exacerbations of the bronchitis on the one
hand, and the suspension of the renal secretion on the other, are
the accidents commonly attendant on the paroxysm of the dis-
ease. We may suppose that either of these affections, or both
of them concurrently, by inducing an accumulation of blood at
the right side of the heart, may cause the paroxysm of cardiac
suffering, attended by anasarca, owing to the general congestion
of the venous system ; and, on the other hand, by overloading the
venai cavse bepaticae, may induce a passive enlargement of the
liver. We may suppose that the repetition of these attacks esta-
blishes a permanent hypertrophy of the latter organ, which in
its turn becomes an exciting cause of disease, so that the cardiac
and hepatic affections are reciprocally cause and effect; and that
such is the case appears probable from the history of them in
many instances.

SIMPLE UNCOMPLICATED DILATATION OF THE HEART.

I have clearly expressed my opinion that this disease is one
of extreme rarity, and as I cannot produce any original observa-
tions of such a condition, it appears better to state generally, that
the diagnosis is to be drawn more from theoretical considerations
than from observed facts. It depends on the existence of signs of
an enlarged and at the same time weakened heart ; and the signs
vary according as the dilatation predominates in the right or left
side of the organ. To declare that we can distinguish between
a dilatation with thinning of the parietes of the heart, and that
form of enlargement where the capacity of the cavities, as well
as the thickness of their walls, is increased, while the force of the

270 DISEASES OF THE MUSCULAR STRUCTURES OF THE HEART.

organ is not augmented, — is to state what is not warranted by cli-
nical experience.

Excluding all considerations of valvular obstruction, or of dis-
ease of the lung or liver, it may be laid down that the dilated
state of the heart is more often seen in the right than the left ca-
vities ; and even under the circumstances now specified, it is a
rare affection : that is to say, if we exclude that form of which
an illustration is furnished by the case of Mr. Colles, a form in
which not only disease of the liver and lung add their quota to
the group of symptoms, but where the gouty condition of the
entire system is an important element, the occurrence of simple
uncomplicated dilatation of the heart, considered without refe-
rence to any muscular degeneration on the one hand, or valvu-
lar obstruction on the other, is so rare an affection that, while we
do not deny the possibility of its occurrence, we must admit that
there is little, if any, clinical observation which would establish
its diagnosis.

The following should be the theoretical diagnostics of such an
affection : —

1. Increase of the area of dulness over the heart.

2. Feebleness of impulse.

3. Feebleness and smallness of pulse.

4. Feebleness of the sounds of the heart.

5. Absence of true valvular murmur.

To these diagnostics may be added the following : — That the
patient may be liable to cerebral attacks, resulting either from de-
ficient supply to the brain or from nervous congestion ; and that he
may exhibit symptoms of dyspnoea on exertion, and the signs of
an overloaded right ventricle, as shown by jugular pulsation, and
perhaps an engorged state of the liver. Finally, a dropsical ten-
dency will probably be manifested.

In speaking of the differential diagnosis between dilatation of
the heart and the combination of dilatation with hypertrophy,
Laennec has stated, that a certain clearness or sharpness of sounds
attends the dilated state. This can hardly be admitted, unless
we suppose a case in which there are the combined conditions
of thinning of the parietes, with an increased vivacity or force of
the muscular contraction. Whether such a state ofthe heart evci

DILATATION WITH HYPERTROPHY OF THE HEART. 271

exists is very doubtful ; and it is not improbable that in the mind
of Laennec the connexion between clearness of sound and thinning
of the parietes of the ventricles was but a corollary to his doc-
trine, that the second, or clear sound, was produced by auricular
contraction. It is true, that in certain cases of great thickening
of the heart a dull sound is produced; and also, that in some ex-
amples of dilatation the sounds of the heart have a sharp or flap-
ping character; but there is really no evidence to show that these
phenomena depend on any mechanical condition ; and it is more
consistent with the present state of our knowledge to attribute
them to a deficient or increased contractile power. Certain it is,
that the most remarkable examples of augmented loudness of both
sounds of the heart are to be met with in hysteria or other ner-
vous affections where no mechanical change of the organ can be
supposed to exist. On the other hand, it may be objected that
the contraction of the right ventricle gives a clearer sound than
that of the left. But we cannot as yet affirm that the sound of
one ventricle can be distinguished from that of the other; and
even if the fact be admitted, there may be other causes for the dif-
ference in sound.

Lastly, it is to be remarked, that although in theory we do
not admit true valvular murmur as a sign of dilatation of the
heart, yet, on the other hand, when the dilatation of the cavities
is carried beyond a certain point, valvular insufficiency may re-
sult, and then a murmur, as in the case already given, is pro-
duced ; which, though having its origin in the valvular orifices, yet
does not proceed from valvular disease.

DILATATION WITH HYPERTROPHY OF THE HEART.

This condition, so common in cases of valvular obstruction or
imperfection, is yet, in its simple form, of very great rarity. In-
deed, in an elementary work on practical medicine, its considera-
tion might well be omitted ; for in a great proportion of cases of
enlarged and thickened hearts, valvular disease in the mitral
or aortic opening, or in both simultaneously, is to be met with.
However, as a few examples of the uncomplicated affection have
been recorded, we may, as in the case of dilatation, state the theo-
retical diagnosis.

272 DISEASES OF THE MUSCULAR STRUCTURES OF THE HEART.

Presuming that the contractile force of the heart is at least not
below the normal state, the following signs will be observed: —

1. Increase of dulness, generally commensurate with the ex-
tent of the organ.

2. Increase of the force of the impulse at the side, and of the
extent of surface over which this impulse can be perceived. This
extension of the area of impulse is one of the best-marked signs
of enlargement of the heart; and a moderate experience will ena-
ble us to distinguish between the impulse communicated by the
surface of an actually enlarged heart and the sensation given in
simple excitement of the organ. To this point we shall presently
return.

3. The sounds are generally augmented, and commonly un-
attended by murmur. Occasionally we meet cases in which the
first sound is attended with the ringing character; but as this
phenomenon occurs in cases of ordinary nervous excitement, and
is absent in dilatation without hypertrophy, it must be referred
to an extreme activity of muscular contraction rather than to the
dilatation, or even thickening of the ventricle.

Cut it is often found that a greatly enlarged heart may exist
without much augmentation of sound or of impulse. The organ
does not contract with vivacity ; and hence, though by the
hand placed over the prsecordial region we recognise a deep and
extended pulsation, we find this pulsation feeble and wanting in
localization. It is not uncommon on dissection to find the heart
much more enlarged than could have been expected from the
sounds, impulse, or pulse, as observed even for a considerable time
before death.

In such cases there is probably more or less of fatty degene-
ration, especially of that kind in which the fat globules are inter-
stitially deposited in the fibre. It may be also that there is a true
deficiency of the nervous power ; or, lastly, that the organ, from
its very bulk, has not sufficient room for full expansion, and, conse-
quently, cannot put forth its entire contractile power. Considered
practically, we gain but little from examining the subject of hy-
pertrophy of the heart when occurring independently of obstruc-
tion or dilatation of the valvular openings. Nor has medicine
been much advanced by our attempts to study the signs of the

DILATATION WITH OH WITHOUT HYPERTROPHY. 273

lesion in this or that cavity; for though the signs of disease in
either ventricle may be declared from a priori reasoning, we are
taught by practical medicine that hypertrophy, with or without
dilatation, is rarely confined to a single cavity.

DILATATION WITH OR WITHOUT HYPERTROPHY OF THE AURICLES.

Although in most cases of dilatation of the heart we find the
auricles, as well as the ventricles, engaged, yet our knowledge of
the disease as affecting the former cavities is very limited. For-
tunately, this is not of much consequence to practical medicine.
We do not yet know of any signs or symptoms by which the dila-
tation of one or both auricles could be directly determined. The
existence of such a state will be probable when we find signs
ol enlargement of the heart, and especially if there be a contrac-
tion of the mitral orifice. Under these circumstances both auri-
cles become engaged, and the left exhibits, as Dr. Adams has
shown, opacity of its lining membrane, and the enlarged openings
of the pulmonary veins. The circle of diseased actions is com-
pleted by the occurrence of pulmonary congestion, and of dilata-
tion of the right ventricle and auricle.

I have already remarked on the difficulty which the anatomical
position of the left auricle offers in any attempt to discover its en-
largement by physical signs. This condition can only be inferred
when we find the signs and symptoms of disease of the right ca-
vities succeeding to narrowing of the mitral orifice. Let us sup-
pose, for example, a patient who, for a certain period, presented
a mitral murmur, but had no symptom indicative of pulmonary
disease or overloading of the heart:— now, if in such a case the
heart’s action should become permanently irregular, — if haimop-
tysis took place, — if the patient suffered from dyspnoea on exer-
tion, while the jugular veins pulsated, and the apex of the heart
could be felt beating in the epigastrium; — we might safely con-
clude that the left auricle was in a state of dilatation and, proba-
bly, hypertrophy; that the pulmonary veins were enlarged; and,
finally, that the obstructive process had affected the right cavities.
The diagnosis, however, will be inferential, for such a case as
I have given, of dulness probably proceeding from enlargement of

VOL i. T

274 DISEASES OF THE MUSCULAR STRUCTURES OF THE HEART.

the left auricle*, must be one of great rarity ; and we have no
demonstrative proof that the explanation of its attending cir-
cumstances was correct. I have already expressed my opinion as
to the uncertainty of the diagnosis which assumes that direct phy-
sical signs attend this condition.

We might, perhaps, go a step further, and say that hypertro-
phy, as well as dilatation of the auricle, may be expected in cases
of narrowing of the mitral opening, while a simply dilated con-
dition would probably occur in its enlarged and patulous state, of
which the case by Mr. Fleming furnishes an example.

But the anatomical relations of the right auricle render it more
favourable for the application of direct diagnosis ; and it is pro-
bably liable to greater distention than the left cavity. There is rea-
son to believe that this dilatation, when carried to an extreme
degree, may be attended by two remarkable physical signs, namely,
dulness on percussion, and a pulsation which is probably diastolic.

Some years since, a man past middle age was admitted into
the Meath Hospital, labouring under symptoms of disease of the
heart, and general venous obstruction. There was considerable dul-
ness to the right of the sternum, unexplained by any disease of the
lung or pleura. The heart was in its natural position ; its action
irregular, and rather feeble than otherwise. Between the second
and fifth ribs, on the right side, and corresponding to the dulness,
there was a deep-seated but most distinct diastolic pulsation. This
was synchronous with the first sound of the heart ; but I am now
unable to say whether murmur was present. For some days I
inclined to the opinion that the case was one of aneurism, as the
signs closely resembled those which we had observed in a case of
true aneurism of the aorta. But when I considered the larity of
true aneurism, and also, that in all the cases of this disease that I
had witnessed, the circulation was but little disturbed, I concluded
against such a diagnosis. The pulsation was clearly different from
that of the ventricle, although synchronous with it. It extended
over a large surface, and had precisely the characters perceived
in an aneurismal tumour in which the pulsation is not energetic.
It is difficult to express in words the character of this pulsation;
but to the experienced clinical observer I shall be easily mtelli-

* See page 204.

DILATATION WITH OR WITHOUT HYPERTROPHY.

275

gible. After a few days the pulsation became less distinct, and
the symptoms of pulmonary congestion more decided. The pa-
tient sank in about a fortnight after his admission. The aorta
was found perfectly healthy throughout its entire course; the
lungs were extremely congested, and had evidently been long af-
fected by Laennec’s emphysema. The right ventricle was dilated
and somewhat hypertrophied ; but the right auricle presented a
most singular appearance when the chest was opened, resembling
a vast purple tumour which concealed the whole of the anterior
portion of the right lung. Its parietes were in many places ex-
tremely thin, while in others the fleshy columns, especially in
the appendix, were hypertrophied. Its cavity contained more
than a pound of fluid but grumous blood.

The great size of the auricle furnishes an easy explanation of
the dulness on percussion, for there was no effusion into the pleura
or consolidation of the lung. The great interest of the case, how-
ever, consists in the occurrence of pulsation, which must be sup-
posed to have been caused by the introduction of blood persaltum
through the auriculo-ventricular opening at each contraction of the
heart. In fact, the auricle had become an aneurism so far as its
mechanical relations were concerned.

This fact seems to open up some new subjects for considera-
tion with reference to the heart’s action in disease. If the au-
ncles may become the seat of a throb, as it were aneurismal,
it may be inquired, whether such a condition would be possi-
ble in the ventricles. If it be admitted that the auricles act per
so.ltum, one of the conditions of such an occurrence would al-
ways exist; and it would only be necessary that the ventricle
should be in a state of great debility, unable to empty itself com-
pletely at each contraction, in order to obtain the conditions ne-
cessary for such an occurrence. I apprehend that such an action
takes place in certain cases of fatty degeneration with dilatation
of the left ventricle, for I have observed instances of this disease
wherein the systolic sound was extremely feeble, yet in which
the impulse was diffused and clearly diastolic, having a close re-
semblance to that produced in a true aneurism of the ascend-
ing aorta. The character of this impulse was altogether diffe-
rent from that produced by contraction of the ventricle. It was

t 2

27G DISEASES OF TIIE MUSCULAR STRUCTURES OF THE HEART.

excentric, and its great dissimilarity to the ordinary impulse in
fatty hearts tends to confirm the idea that it was produced in the

ventricle by the systole of the auricle.

We should expect that the aneurismal pulsation of the auricle
would be more likely to occur in the right than in the left cavity,
when we recollect the frequency of the reflex jugular pulsation,
and the natural imperfection of the tricuspid valves.

Let us now sum up what has been said on dilatation of the
heart with or without hypertrophy.

1. That dilatation of the whole heart, or of any corresponding
pair of its cavities, or of any single cavity, considered as a purely

local disease, is one of extreme rarity.

2. That while uncomplicated dilatation of the heart is so
rarely met with, the opposite form is of common occurrence.

3 That the cases of complicated dilatation are of three kinds.
In the one the complication is related to disease of the orifices ; in a
second form, to obstruction in organs remote from the heart ; and
in the third, it appears to arise from a debilitated state of the car-
diac muscles themselves.

4. That in the last condition the nervous deficiency or weak-
ness of the heart is often connected with an early stage of fatty

transformation of the muscular fibres.

5. That in cases of complication with valvular disease, the di-
latation of the cavities, and especially of the left ventricle, appears
to be the effect of regurgitation rather than of mere obstruction to

the exit of blood.

6. That dilatation of the heart, in its most common form, is
met with as one of a triple group of local diseases, m which the
heart, lungs, and liver appear to be affected.

7. That in many of these cases the local affections are them-
selves secondary to certain morbid states, of which the most com-
mon are a gouty diathesis in an enfeebled subject, the anamiic or

scorbutic state, or some other form of cachexia.

8 That in this condition both the structure and functions of
the lung are commonly deranged, and we meet with chronic bron-
chitis, dilated tubes and air-cells, and various degrees of pulmo-
nary congestion.

9, That again the liver is the seat of deranged structure and

DILATATION WITH OR WITHOUT HYPERTROPHY.

277

function. It is generally enlarged, and yet its volume is observed
to increase with each exacerbation of the disease.

10. That this paroxysmal swelling of the liver may rapidly
subside, leaving the organ in its former state of enlargement at
the close of each exacerbation of disease.

11. That in this triple combination the patient is liable to pa-
roxysms of cardiac asthma, in which the three organs show symp-
toms of extreme derangement ; that of the heart, by increased
irregularity, rapidity, and force of action ; that of the lung, by
lividity, dyspnoea, and augmented rale; and that of the liver, by
a rapid increase of its bulk, even though the permanent condition
of the organ be one of hypertrophy.

12. That derangement of function in any o'f these organs may
induce a paroxysm of disease, and that it is frequently impossible
to determine whether disturbance of the heart, lung, or liver, has
been the exciting cause of the attack.

13. That we cannot accept the opinion of Laennec, — that
the distinctive sign of dilatation is the clearness of sounds during
the systole and diastole of the heart.

14. That the frequent combination of weakness with dilatation
of the heart should lead us to expect a feebleness of the sounds,
and this more especially when it is recollected that the weakness
is seldom unconnected with an organic change.

15. That dilatation of the left auricle, attended with more or
less of hypertrophy, may be expected to exist in cases of mitral
disease with contraction.

16. That we are not yet justified in declaring that the dilata-
tion of the left auricle is attended with any special physical sign.
It is probable, however, that in one observed case the sign of dul-
ness on the left side, suddenly occurring and stretching from the
base of the heart upwards, may have been induced by distention
of the left auricle.

17. That distention of the right auricle has been found to be
attended with dulness, and with a diastolic pulsation synchronous
with that of the ventricles, so as to simulate aneurism of the aorta.

18. That there are some grounds for believing that a similar
action may be produced in a ventricle, when its contractile force
is much diminished and its capacity increased.

278 DISEASES OF THE MUSCULAR STRUCTURES OF THE HEART.

19. That we are not in a position to declare why it is that in
one case we have dilatation without thickening, and in another,
dilatation with hypertrophy.

20. That dilatation with preservation of the natural thickness
is to be considered a form of dilatation with hypertrophy — ( Hy-
pertrophic clilatatoire of Forget).

21. That dilatation with increase of thickness may be met
with although no valvular disease exists.

22. That, however, it is most commonly seen in cases of val-
vular lesion.

23. That hypertrophy with dilatation of the left ventricle may
arise on the one hand from the regurgitant disease of the aortic
orifice; and on the* other, from the permanently dilated condition
of the mitral opening.

24. That hypertrophy and dilatation of the left auricle are met
with in cases of mitral obstruction.

25. That hypertrophy and dilatation of the right cavities are
seen to occur in cases of pulmonary congestion ; but that in many
cases the point of departure of the entire disease seems to be a
contraction of the mitral opening.

In connexion with the subject of dilatation of the heart in ge-
neral, we shall now notice the not unfrequent case of palpitation
of the heart attended with enlargement of the thyroid gland and
eyeballs. Yet, although some form of dilatation of the heart has
been found in a few cases of this disease, we cannot but consider
it as a special affection, in which the organic change is secon-
dary to functional derangement.

INCREASED ACTION OF THE HEART AND OF THE ARTERIES OF THE

NECK, FOLLOWED BY ENLARGEMENT OF THE THYROID GLAND AND

EYEBALLS.

The following are the important features of this disease : —

1. Increased force and rapidity of the heart’s action, without
fever, and of long continuance.

2. Excited action of the carotid and thyroid arteries.

3. Enlargement of the thyroid gland, varying with the force
of the heart.

AFFECTION OF THE HEART AND THYROID GLAND. 279

4. Enlargement of the eye-balls, without any disease of the
orbits or brain.

This affection is most commonly met with in women, but
males are not exempt from it; and it may arise at various ages.
I have seen it in a lady upwards of sixty years of age.

The point of departure of the disease is the heart, the action of
which becomes rapid and occasionally tumultuous ; and subse-
quently, after a period of time varying in different cases, we observe
the enlargement of the thyroid gland and also of the eye-balls, at-
tended with a pulsation of the whole neck, especially in its lateral
portions, and in the seat of the thyroid gland itself. When this
pulsation is examined, three causes are found to concur in its
production, or, rather, there are three different kinds of pulsation.
We have, first, the arterial pulsation simply ; next, the diastolic
throbbing of the gland ; and lastly, a pulsating thrill in the gland
and veins of the neck, which is similar to the thrill of an aneu-
rismal varix.

The thyroid enlargement and pulsation appears to precede the
increase of volume of the eye-balls. Dr. Graves mentions three
cases of palpitation in females, in which the tumefaction of the
gland, arising with each attack, and diminishing with its subsi-
dence, was observed. In these cases the enlargement of the eyes
had not yet occurred ; but, doubtless, had the disease continued
sufficiently long, that complication would have been produced.

Some years ago, when the disease was but little known, a case of
this condition of the thyroid gland in a young woman was actually
mistaken for aneurism, and a day appointed for performing the ope-
ration of tying the carotid artery. Happily, the true nature of the
affection was discovered in time, and the patient was cured by
the use of sedatives and the preparations of iodine. The tumour
in this case was larger than a hen’s egg, and somewhat flattened
anteriorly. Its pulsations were violent, and over every part of
its surface the thrill of aneurismal varix could be felt. This was
attended with the sounds peculiar to this condition. The eyes had
not become enlarged.

This disease of the thyroid differs in some respects from ordi-
nary bronchocele. The liability to its production is in no way
connected with any of the influences of soil or climate. The

280 DISEASES OF THE MUSCULAR STRUCTURES OF THE HEART.

volume of the tumour Is remarkably variable; but even in cases
where the disease has existed for several years, it seldom attains
to a large size. Dr. Graves indeed states that the tumour is
never sufficiently large to cause deformity of the neck, but I have
seen two cases in which considerable deformity existed. The same
author observes, that it is distinguishable from bronchocele by its
becoming stationary just at that period of its development when
the growth of the latter usually begins to be accelerated. I have
observed this arrest of the growth of the tumour in several cases ;
in one instance, to which I shall again allude, where the disease
occurred in the male, the tumour became more solid, and the
thrilling sensation and murmur disappeared from various points
of the surface. After some years all thrill and murmur had dis-
appeared ; the tumour felt solid and nearly inelastic, while a large
varicose vein, with thickened parietes, ran over the front of the
tumour ; in the course of this vein, and in no other situation, the
murmur still existed.

The accompanying phenomena, referrible to the action of the
heart, the arteries in the neck, and the peculiar condition of the
eye-balls, will be sufficient to establish the diagnosis.

But although these cases, which have so strong a generic re-
semblance, differ in their history and accompanying conditions
from those of ordinary bronchocele, we cannot, without risk of
error, describe them as examples of a perfectly distinct disease.
The remarkable preponderance of both forms of the affection in fe-
males, at least m this country, is important, and if to this be added,
that no instance has been observed of the affection we are now
describing occurring before puberty, — that the structures engaged
in both affections appear to be the same, — that in many cases of
ordinary goitre, hysterical paroxysms, or uterine derangements
produce an increase of the swelling, — and finally, that in one case,
at all events, the thrilling tumour of the neck subsided under the
use of iodine, — there is good reason why we should not draw too
■strongly the line of demarcation between the diseases.

With respect to the enlargement of the eye-balls, we may ob-
serve that it occurs last in the chain of phenomena, and probably
arises from iin augmentation of the vitreous and aqueous humours
of the eye. Both eyeballs are simultaneously and equally aflectcd,

AFFECTION OF THE HEART AND THYROID GLAND. 281

and so far from signs of sanguineous congestion existing, the eye
has a singularly clear and transparent appearance, which in some
cases amounts to a morbid brilliancy. There is a peculiar staring
expression caused not only by the prominence of the ball, but
from the line of the sclerotic coat which is seen surrounding the
cornea to a greater or less extent. Under these circumstances a
maniacal expression is produced. As the disease advances, the
protuberance of the globe may become extraordinary. It pro-
trudes outwards and downwards, and the lids, being no longer
able to cover the eye, the patient sleeps with the eyes open ; yet
it is a most singular fact that the power of vision is not in any
way injured, nor is the patient rendered liable to ophthalmia. I
have known a case in which, for upwards of a year, the eye was
never closed, yet in which no vascularity of the conjunctiva, nor
any form of ophthalmia, ever occurred.

When emaciation takes place, the expression of the counte-
nance produced by this staring, protuberant, and never-closing
eye, is most painful and extraordinary. Yet so far as the eyes
are concerned, the patients make little or no complaint. What
* they principally suffer from is the palpitation of the heart, the
throbbing in the neck, and the sensation of fulness in the head
and constriction when the head is bent forward so as to compress
the thyroid tumour.

In most instances we observe a want of proportion between
the force of the pulsations in the arteries of the neck and those in
other parts of the system. The carotid and thyroid arteries may
pulsate with vehemence, so as to give the idea that all the ves-
sels of the neck are enlarged and in a state of morbid activity, yet
the radial pulse be small and weak, and only rapid or irregular
according to the state of the heart’s action.

The exciting causes of this affection are various, but all seem
to have acted first on the heart. Amenorrhcea, with or without
hysteria, is a common cause. In young women, mental anxiety
and the effect of terror may produce it. I have known a remark-
able instance of the latter cause inducing the disease in a lady
who had previously been healthy. In a case of the disease in
the male subject, long-continued haemorrhage from piles was as-
signed as the cause.

282 DISEASES OF THE MUSCULAR STRUCTURES OF THE HEART.

It has not been found associated with any form of carditis, or
to be produced by hepatic disease. Indeed, all that we can say
as to its nature amounts to this, that it is a special form of cardiac
neurosis, which may eventuate in organic disease. Whether the
nervous excitement is propagated to the arteries in the neck is a
question I have often proposed to myself, for there is something
in their action more than can be explained by the force of the
heart. If we compare the pulsations of the carotid with those ol
the radial arteries, the difference is most striking; the former
being violent in a high degree, while the latter are small and weak,
only corresponding with those of the carotids in their fiequency.
Exceptional cases are, however, met with.

In this affection we commonly observe that double pulsa-
tion of the arteries to which we have before alluded ; and its ex-
istence in the neck alone is another evidence of a local vascular
excitement.

This pulsation is perceptible to the hand and ear, and has pre-
cisely the character of the double pulsation in an aneurism. It is,
as it were, its diminutive. Yet this condition is peculiar to the
carotid arteries, and its existence could never be conjectured from
any character of the radial pulse.

The disease is capable, if not of cure, at least of great amelio-
ration. The enlargement of the eye-balls diminishes, so that the
staring expression disappears, though a certain fulness ol the globe
may remain. The thyroid gland is lessened in volume and ap-
pears to become more solid ; it loses the violent pulsation and the
purring thrill, or the latter may be confined merely to certain
parts of its surface. The excitement of the arteries subsides, and
the heart becomes comparatively tranquil, yet these changes le-
quire a long period for their completion. I am not in possession
of any proof of the complete cure or resolution of the disease,
when fully formed, though we have no reason to believe such an
occurrence impossible.

Dr. Parry11 has given several cases of enlargement of the thy-
roid gland in connexion with affections of the heart. In the first
of these cases the patient had been attacked by acute rheumatic

11 See “Collections from the unpublished Medical Writings of the late Caleb Hilliard
Parry, M.D.” p. 111. London: 1825.

AFFECTION OF THE HEART AND THYROID GLAND. 283

fever consequent on her lying-in. This was followed by palpita-
tion of the heart, which gradually increased in force and frequency
until Dr. Parry commenced his attendance, when it was so ve-
hement that the whole thorax was shaken at each systole of
the heart. The pulse was 156, very full and hard, irregular in
strength, and intermitting at least once in every six weeks. She
suffered from symptoms resembling cardiac asthma, attended with
slight hemoptysis, and had also frequent and violent pains about
the lower portion of the sternum. “About three months after
lying-in,” says Dr. Parry, “ while she was suckling her child, a
lump about the size of a walnut was perceived about the right
side of the neck. This continued to enlarge till the period of my
attendance, when it occupied both sides of her neck, so as to have
reached an enormous size, projecting forwards before the margin
of the lower jaw. The part swelled was the thyroid gland. The
carotid arteries on each side were greatly distended; the eyes
were protruded from their sockets, and the countenance exhibited
an appearance of agitation and distress which I have rarely seen
equalled. She suffered no pain in her head, but was frequently
affected with giddiness”11.

This patient soon afterwards died with the usual symptoms of
anasarca and disease of the heart. No dissection is reported.

In the second case, a lady in consequence of a fright became
subject to palpitation of the heart and various nervous affections,
and in about a fortnight she observed a swelling of the thyroid
gland, which subsequently varied at different times so as to be
once or twice nearly gone. When seen by Dr. Parry, the gland
was swelled on both sides, but especially on the right; the pulsa-
tion of the carotids was very strong and full, but predominating
on the right side. She stated that she had formerly been sub-
ject to headachs, which had ceased since the commencement
of the swelling. The pulse was 96, small, hard, and regular. Ten

a The combination of disease of the heart and enlargement of the thyroid gland is no-
ticed by Flajani. See his “ Collezione cTosservazioni e rijlessioni di Chirurgia .” Roma :
1800, vol. iii. p. 270. A case is quoted in the Medico- Chirurgical Review, vol. i., from
the New England Journal, October, 1820, in which, after violent palpitations, a pulsat-
ing tumour extended high above the right clavicle, and presented a strong thrilling
sensation. The symptoms subsided soon after an attack of hscmatcmesis.

284 DISEASES OF THE MUSCULAR STRUCTURES OF THE HEART. %

ounces of blood were taken from the arm, and tills operation was
followed by evident diminution of the tumour; and after her next
menstrual period the swelling of the thyroid, which had returned,
was found to have almost disappeared. On the next ensuing pe-
riod, the tumefaction increased previous to the discharge, when
it again diminished.

The next three cases are examples of the combination of en-
largement of the thyroid with symptoms of organic disease ol the
heart. The tumefaction in all of them was attended with increased
action of the carotids, and in two cases the thyroid swelling evi-
dently followed a long-existing cardiac disease. In the sixth case,
a married woman, with a very long neck, who never had had a
family, after keeping her feet a quarter of an hour in cold water
for the relief of chilblains, was attacked with violent pain in the
region of the heart. For five years after that period these attacks
used to return, and were subsequently attended with palpitations
and attacks of difficulty of breathing, with globus hystericus.
During the palpitation, and indeed at other times, she had vio-
lent beating in the head and pulsation of the neck; and after one
of these attacks, which was unusually severe, the thyroid gland be-
gan to swell. The subsequent reports of this case furnish nothing of
importance. Two more cases are given, but they do not contain
any novel observation. No dissection is recorded by Dr. Parry,
nor was the enlargement of the eyes observed but in a single case;
and, indeed, if we except the second, and perhaps the sixth, case,
they are examples either of enlargement of the thyroid gland suc-
ceeding to a long-existing organic disease of the heart, or of acci-
dental disease of that organ in a case of bronchocele.

This disease, however, remained but little known until the pub-
lication of Dr. Graves’s Lectures in 1835, afterwards embodied in
his “ Clinical Medicine.” This author first pointed out the dis-
tinction between the enlargement of the thyroid in these cases and
that in ordinary goitre. He suggested that the thyroid body might
be slightly analogous to the tissues properly called erectile, and
that the globus hystericus is not necessarily a simple nervous affec-
tion, but really arises from a temporary enlargement of the thyroid.

I communicated the following case of this affection to Dr.
Graves after hearing his clinical lecture on the combination of

AFFECTION OF THE HEART AND THYROID GLAND.

285

palpitation of the heart with enlargement of the thyroid gland.
A young lady, of delicate make and nervous constitution, be-
came affected with various forms of hysterical and neuralgic dis-
ease. She complained of debility upon exertion, and lost flesh
and colour; she suffered from palpitation of the heart; and in the
course of a few months it was observed that the pulse was never
under 120. It frequently rose to nearly 140, and was small and
compressible. The contrast between the action of the radial and
carotid arteries was most remarkable, the pulsations of the latter
being violent and jerking, attended with a deep bellows murmur,
and conveying the idea that the arteries themselves were enlarged.
The action of the heart had that sudden, sharp, and jerking cha-
racter which is found in nervous palpitations, while its rate ne-
ver fell below 120. The eyeballs were now observed to enlarge
gradually, until at length their condition imparted to the counte-
nance an unearthly expression. The tumefaction continued to
increase until the globes of the eyes appeared to protrude from
the orbits, looking downwards and forwards, and exhibiting a zone
of the white sclerotic round the entire of the cornea of at least two
lines in breadth. The lids could only be half closed ; and the ap-
pearance of this lady during sleep, with these great brilliant eyes
yet open, can never be effaced from my memory. It was remark-
, able that the conjunctiva was never vascular, nor were any symp-
toms of ophthalmia developed, such as we see occurring in the
open eye, which attends on the facial paralysis described by Sir
Charles Bell. Notwithstanding the unnatural enlargement of the
organs, there was no alteration in the power of vision. The thyroid
gland was increased in volume, and, formed an elastic tumour,
in shape somewhat resembling a horse-shoe. It was at first
soft, but soon became harder, though still elastic. It very soon
attained its maximum development, forming a tumour about the
size of a small orange, after which it did not continue to in-
ciease. The condition of the eyes was to a certain degree va-
riable, but they remained greatly enlarged up to the period of
death. She suffered little from the state of the heart, thyroid, or
eyes, her principal distress being the occurrence of severe facial
neuralgia. Little change occurred in the symptoms for upwards
of two years, and this lady sank with general anasarca and pulmo-

286 DISEASES OF THE MUSCULAR STRUCTURES OF THE HEART.

nary congestion ; in short, with the symptoms generally attributed
to dilatation of the heart.

Case XXVI. — Long -continued excitement of the Heart in a, male
subject; Enlargement of the Eyeballs and of the Thyroid Gland;
Increased action of the Vessels of the Neck , with murmur in the
tumour similar to that of Aneurismcd Varix; Ultimate subsi-
dence of the morbid action of the Heart , with diminution and har-
dening of the Tumour in the Neck.

John M'Keon, aged 48, tall, spare, and dark-complexioned,
of a nervous and sensitive temperament, was admitted to the Meath
Hospital during the year 1838, labouring under violent palpita-
tion of the heart, general arterial excitement, and enlargement of
the thyroid gland. His history was, that he had for many years
been healthful, and of regular habits, never addicted to intempe-
rance, and working laboriously at his occupation. About seven
years ago, after a hard day’s work and exposure to inclement wea-
ther, he was attacked with violent palpitations of the heart, unac-
companied by pain or any other symptom except slight vertigo.
He attributed these to obstinate constipation, from which he had
long suffered. They subsided after three months’ continuance,
and from that time he continued healthy, with the exception of
a small tumour that appeared some years ago in the region of
the thyroid, but which gave him no annoyance. In January,
1838, the palpitations again returned, and in about six weeks
became so violent as to cause him to seek admission into hospital.
At that time he was much emaciated, and suffered from general
debility; it was chiefly the palpitation and arterial excitement of
which he complained, the thyroid enlargement causing him little
or no suffering. His appetite was good, and he slept well ; pulse 96.
His appearance, however, was very peculiar, and at once arrested
attention. Situated over the trachea, and corresponding to the
part occupied by the thyroid gland, was seated a large tumour,
of soft and flabby consistence, most prominent laterally, and re-
sembling in many respects a bronchocele of moderate growth. A
remarkable thrill, resembling that perceived in aneurismal varix,
was communicated to the hand placed on the tumour, particularly

AFFECTION OF THE HEART AND THYROID GLAND. 287

over its left lobe. Large and swollen veins ramified over its surface ;
and when the stethoscope was placed on it an intense musical
murmur was audible. The same existed in the carotids, but the
thrill in the tumour appeared to be independent of these vessels.
His eyeballs were very prominent and enlarged ; he had no stridor
or dysphagia, but small portions of food occasionally pass into
the nares. His heart pulsated violently between the fourth and
fifth ribs, but no murmur accompanied its sounds. The carotids
pulsated visibly, as also the left subclavian. A particular examina-
tion of the tumour discovered that when the finger and thumb
were made to grasp and compress the vessels of the neck, the vi-
bration at first became stronger, but as the pressure was increased,
it altogether subsided, though the impulse of the vessels continued.
The stethoscope being applied over the tumour pending the pres-
sure on the left side, the murmur ceased on the corresponding side,
but the thrill, and consequently the sound, continued on the op-
posite side. The tumour which at the time of his admission into
hospital measured 16£ inches round the most prominent part to
the sixth cervical vertebra, after a short period was reduced to
15. The palpitations had become less violent, the thrill and the
tumour, particularly on the right side, greatly decreased, and he
left the hospital greatly improved in every respect.

In a short time after, however, all his former symptoms re-
turned in a more aggravated degree, and he also suffered from
diarrhoea and haemorrhoids. He was again admitted into hospital.
The palpitations had returned, and he complained of violent pul-
sation of the abdominal aorta. There was no material change in
the tumour from that before described, except that it was somewhat
diminished in size, but the thrill and musical murmur continued
as intense as ever. The vessels of the neck were now enormously
swollen, yet no immediate contact could be discovered to exist
between the carotids and the tumour. His heart pulsated vio-
lently between the sixth and seventh left ribs. An occasional
intermission existed in the beats of the heart, of which the patient
himself was conscious. The first sound was remarkably loud, the
second, shorter, sharper, and weaker than natural ; a kind of mus-
cular murmur accompanied the heart’s action, which was appa-
rently created by the violence of the impulse, but no valvular mur-

288 DISEASES OF THE MUSCULAR STRUCTURES OF THE HEART.

mur accompanied either sounds. The pulsation of tire abdominal
aorta was excessively violent, and the slightest pressure over it crea-
ted a murmur. His eyeballs still continued prominent and enlarged.
There seemed in this man to be a tendency to irregular distri-
bution and division of the arteries. The ulnar artery came offmuch
higher up than usual, and ran for some distance superficial. The
radial sent off a large branch which crossed the arm above the
wrist. His treatment consisted in the use of anti-nervous medi-
cines, anodynes at night, and subsequently the long-continued
use of digitalis. Under this treatment he regained flesh and
strength. The arterial excitement became very much reduced,
and the pulse seldom rose higher than 80. The intermission in
the beats of his heart disappeared after a fortnight, and the pulsa-
tion of that organ became much reduced in force. He left the
hospital after six weeks, and since that time has continued to
improve, as the following observation, made several years since
his last leaving the Meath Hospital, will show: Action of the

heart tranquil, and no murmur accompanied the sounds. The
enlargement of the eyes had almost entirely subsided, and the tu-
mour itself was much reduced in volume, and to all appearance
solid. There was no thrilling murmur in any part of it save in
the course of a tortuous vein which ran from above downwards
over its anterior surface. This vein had a loud murmur and a
slight purring thrill.

For some years subsequently I had opportunities of seeing this
patient, and of observing the decline of the symptoms. It ap-
peared to me that the process of improvement began in the heart,
the action of which gradually became more natural. In the eyes
improvement was next exhibited, yet even after the enlargement
had subsided, they preserved a certain intensity of expression. It
is difficult to say how much of this was natural, for the patient was
a man of erect carriage, and of a bold and determined character.
On my last examination I found that all signs and symptoms of
cardiac affection had subsided; the thyroid tumour had become
everywhere solid ; it was nearly hemispherical ; it had lost its pul-
sation, and no trace of thrill or of the humming sound could be
discovered. The vein formerly observed was as large as the finger,
and traversed the tumour a little to the left of the mesian line,

AFFECTION OF THE HEART AND THYROID (STAND.

289

lying in a sulcus formed in . the substance of the tumour, above
the edges of which it was slightly raised. The coats of this vein,
throughout the entire course of which a purring thrill and a sin-
gularly hoarse murmur were perceptible, appeared extremely thick.
The throbbing of the carotids was gone, and the jugular veins
were in a perfectly natural state.

There are some circumstances in this case which are worthy
of special notice. The first attack of disease occurred seven years
before the patient’s admission into hospital, when he had violent
palpitation of the heart, which, after continuing for three months,
subsided. He remained healthy until about ten months before
his admission, with the exception of a small tumour of the thy-
roid gland, which gave him no annoyance, although it had existed
for several years. This seems to show that in this special combi-
nation the thyroid gland may remain for a time indolent, and
again take on a morbid action when the heart becomes a second
time affected.

Lastly, it is worthy of notice, that the arterial excitement in
this case was not confined to the vessels in the neck. The patient,
at a time when the disease was at its height, suffered from in-
creased action of the abdominal aorta. On the other hand, it is
certainly true, that in many cases an extraordinary disproportion
may be found between the force of the arteries in the neck and
in the extremities.

It is probable that the following classification of these cases
may be adopted : —

1. The pulsating and thrilling thyroid tumour succeeding to
an increased action of the heart.

2. An indolent and non-pulsating tumour existing for a length
of time without any remarkable alteration in the action of the
heart, but, consequent on the attack of palpitation, taking on the
character of aneurismaj varix.

It may be that in this last division of cases there is a greater
liability to the production of large tumours of the neck, which
consist, on the one hand, of the altered thyroid tumour, and on the
other, of vast dilatations of the veins, forming, as it were, sepa-
rate tumours on each side of the gland. A case of this sort is
noticed by Sir Henry Marsh, and there is a cast of a great tu-

vol. i. ir

290 DISEASES OF THE MUSCULAR STRUCTURES OF THE HEART.

mour, exhibiting prodigious dilatation of the veins, as well as of
the thyroid, in the Museum of the Richmond Hospital. In this
case pulsation and fremitus existed to a remarkable degree.

The following example of this condition was communicated
to the Pathological Society of Dublin in 1841, by Sir Henry
Marsh. The patient was a person of tall stature; she suffered
from palpitation of the heart and dyspncea, increased by exercise
or mental emotion. The action of the heart was irregulai and
peculiar : three beats followed in succession ; the first, strong and
distinct; the second, closely following, had a double character;
and the third appeared more distant. The interval of repose then
succeeded. There was no bellows murmur. The patient pre-
sented all the characters of the disease under consideration, namely,
remarkable engorgement of the veins of the neck, prominence
and protrusion of the eyeballs, and enlargement of the thyroid
gland. It was observed that the swelling of this organ increased
or diminished according as the action of the heart was more or
less violent, and this swelling was attended with corresponding
tumefaction of the veins of the neck, so that the external jugular
veins formed tumours on each side, giving an extraordinary ap-
pearance to the patient. The prominence of the eyeballs, how-
ever, was not so well marked in this case as in others which he
had seen. After a long illness, death occurred from gangrene of
the extremities, which had been preceded by erysipelas and ana-

sarca. .

On dissection the thyroid gland exhibited an irregularly lobu-

lated surface, the lobules or cysts containing a quantity of clear fluid.
The internal jugular vein on the right side was much dilated, mea-
suring when emptied by puncture an inch and a half across. It
was filled with dark fluid blood. One of the enlarged lobes of
the thyroid body lay over the carotid artery. The lungs were
forced upwards.

Both auricles, but particularly the left, were found much di-
lated. The left ventricle was dilated and hypertrophied, though
not to a very great degree. The auriculo-ventricular valves, on
both sides, exhibited thickened margins; the disease apparently
proceeding from depositions of fatty granular matter under the
membrane. The right valves were more affected than the left.

AFFECTION OF TIIE HEART AND THYROID QLAND.

291

The following case was communicated to me by Professor
Smith, and is of value, as showing that the thyroid arteries are
engaged in the disease.

An unmarried woman, of florid complexion, and with every
appearance of robust health, was admitted into the Richmond
Hospital, under the care of the late Dr. M‘Dowel, complaining of
palpitation of the heart and occasional vertigo. She exhibited
the physical signs of hypertrophy of the left ventricle, but with-
out any decided evidence of valvular disease. There was a con-
siderable enlargement of the thyroid gland, principally owing to
hypertrophy of its right lobe. The thyroid arteries could be
felt pulsating strongly. The eyes were large and brilliant, but
were not protruded. Shortly after her admission she was seized
with apoplexy, which speedily proved fatal.

On examination the left ventricle was found hypertrophied to
a great degree, and its cavity much dilated, — the slightest appear-
ance of the first stage of disease of the aortic valves existed, —
but they were still competent to close the orifice. The thyroid
arteries were greatly enlarged and remarkably tortuous. The
brain exhibited the usual appearances of apoplexy with extrava-
sation. The thyroid gland was enlarged, but no dilated veins
could be seen ramifying on the surface of the neck.

The last case of this affection which I have observed is that of
a gentleman, aged 33, who had suffered from two attacks of the
swelling in the neck. The first appearance of the disease took
place about four years ago, when he found that his neck was gra-
dually enlarging. 'Ihis patient was of a nervous temperament,
and had been exposed to much mental annoyance. His health, too,
had suffered from intense application to study. Under the influ-
• cnee of change of air and occupation the swelling of the neck
gradually disappeared, and in about a year subsided. Thus he
continued until six months since, when, after severe mental ex-
ertion both by day and night, the symptoms returned, and he
began to suffer from difficulty of breathing, and a feeling of con-
striction in the neck. The circumference of the neck progressively
increased, so that he was obliged to enlarge his shirt-collars again
and again. His eyes were suffused and red, but he did not suffer
from palpitation of the heart nor from dysphagia. At this time,

u 2

292 DISEASES OF THE MUSCULAR STRUCTURES OF THE HEART.

in consequence of being informed by bis medical attendants that
bis disease was aneurism, a great increase oi nervous excitement,
and consequently of tbe local disease, took place. When I saw bim,
the circumference of tbe neck was greatly augmented, giving
something of the tippet-like appearance which is occasionally ob-
served in aneurism of the aorta ; but this was not produced by
oedema. The thyroid gland was greatly enlarged, forming a flat
tumour, on each side of which vast dilatations of the veins, form-
ing elastic swellings having a sacculated appearance, could be
seen. I could not find any fremitus, but the central portion of
the tumour had a diastolic pulsation, which anticipated the pulse
of the radial artery by a short but distinct interval. A deep sys-
tolic murmur, loudest at the top of the sternum, and feebly heard
under the clavicles, was perceptible. The heart’s action was ex-
cited but regular, and no valvular murmur could be found.

Although differing in some particulars from those already
given, this case is worthy of study. The eyes were to a certain
degree enlarged, and the original cause of the disease was not
alone nervous excitement, for at the time of the first attack the
patient was living in a district where goitre is endemic. The
important points of difference were the existence of the venous
tumours, and the absence of the thrill and sounds which so closely
resemble those of aneurismal varix. The seat of the systolic mur-
mur was in all probability in the thyroid arteries.

If we now review what has been said on this disease, we must
admit that our knowledge of the affection is still very imperfect,
for although cases of this description are not unfrequent, yet we
possess little information derived from dissection as to their patho-
logical nature. A few carefully conducted examinations of the
state of the heart, aorta, carotid and thyroid arteries, and, lastly,
of the eyeballs and venous system of the neck, would supply an
important deficiency in cardiac pathology. It is true, that we
might thus learn the result, rather than the cause of the disease,
but even this would be of great service to practical medicine.

In the present state of our knowledge we may conclude that
this disease, so well marked in its triple character, is originally a
functional and not an organic affection ; for, although m the cases
observed by Sir Henry Marsh and Professor Smith, organic alte-

AFFECTION OF THE HEART AND THYROID GLAND.

293

rations of the heart were found, yet there is good reason to believe
that these changes were long preceded by a special nervous excite-
ment. We find that the confirmed disease is capable of reso-
lution, as in Case xxvi. We find also, that minor forms are
susceptible of cure, and that whether we consider the subjects most
liable to the affection, or its ordinary exciting causes, there are
strong reasons for holding that the disease is originally a neurosis
of the heart, and, perhaps, also of the cervical vessels themselves.
To these considerations may be added the important fact, that in
hypertrophy of the heart, as it is commonly met with, — in other
words, in that condition which appears most favourable for causing
an increased flow of blood to the neck and head, this combination
is rarely to be seen.

The affection of the thyroid gland itself differs from that in
ordinary bronchocele in several points of view. In most cases, as
Dr. Graves has observed, it becomes stationary after having at-
tained a certain development, and though a greater amount of
deformity may occur than that which he thinks possible, yet I
have never seen in this disease the vast enlargement of the thy-
roid which occurs in ordinary bronchocele.

But the important distinctive mark is the existence of the
peculiar thrill similar to that of aneurismal varix. In some pa-
tients this sign is equally developed over the whole surface of the
tumour, while in others it is more localized. We cannot as yet
declare whether the seat of this thrill and extraordinary murmur
is in the branches of the thyroid artery or in the veins, or whe-
ther there may not be a morbid condition of the entire capillary
system of the tumour. Finally, we observe venous murmur in
the superficial veins, and a bellows murmur, the seat of which is
probably in the thyroid arteries, but which may occasionally be
heard at the upper portion of the sternum and under the clavicles.
This murmur occurs without any disease of the aorta or of the
heart.

In cases of recovery, the thyroid tumour becomes smaller and
apparently solid, and the thrill and murmur both disappear, al-
though they may remain in some of the altered veins of the neck.

The principal supply of blood to the thrilling tumour appears
to be from the inferior thyroid arteries. In Professor Smith’s case

294 DISEASES OF THE MUSCULAR STRUCTURES OF THE HEART.

the carotids and superior thyroids were unaffected, while the in-
ferior thyroids were so enlarged as to equal the brachial artery in
dimensions. The fact, as observed in Case xxvi., of our being
able to command not only the diastolic pulsation, but the pur-
ring thrill, by pressure exercised at the base of the tumour and
immediately above the clavicles, confirms this opinion ; and it will
be recollected that while the thrill ceased, the impulse of the ca-
rotids continued, — it will be recollected also, that the first effect
of pressure was to increase the intensity of the thrill and the loud-
ness of the sound, but that both thrill and sound disappeared when
the compression was carried still further. So far as a single ob-
servation can go, this indicates that the principal seat, both of the
thrill and murmur, is in the dilated veins, and we may hold that
the augmentation of these signs took place in consequence of the
increased flaccidity of the vessels, when pressure caused a dimi-
nished supply. We here apply the principles indicated by Dr.
Corrigan, when he speaks of murmur and tremor in connexion
with disease of the arteriesa.

Our knowledge of this disease from dissection is so scanty that
little that is satisfactory can be said with respect to the state of the
thyroid arteries and of the veins. In the case observed by Pio-
fessor Smith, the thyroid arteries were enormously enlarged and
tortuous, and in that by Sir Henry Marsh, the right internal ju-
gular vein was found' distended. Indeed, there can be little doubt
that a disposition to dilatation of all the veins of the neck exists

in this disease11.

. On Permanent Patency of the Mouth of the Aorta. Edinburgh Medical and Sur-
gical Journal, vol. xxxvii. p. 230.

b In speaking of vascular bronchocele, Hasse observes that all the blood-vessels are
amplified, the veins in particular forming very dense, capacious, often knotted plexuses,
and the whole texture consisting apparently of a dense coat of vessels. The substance of
the gland has almost entirely lost its granular character ; it is flabby and dark red. A ter
death the tumour collapses considerably, and can only be restored to its ongmal s.ze by
artificial injection. The walls of the arteries and veins are attenuated ; the dilated mem-
branes of the vessels contain considerable clots, and capacious cavities are found filled
with black coagulated blood (see Dr. Swain* translation, p. 387). It is probable
that there are more forms than one of the vascular bronchocele ; and though we might
thus designate the condition of the thyroid in the afTection described in the text as a orm
of vascular bronchocele, it is obvious that the disease is but a link in a chain of various

morbid actions.

AFFECTION OF THE HEART AND THYROID GLAND.

295

The condition of the eyeballs is one on which dissection has
not as yet furnished us with any information ; but we cannot come
to any other conclusion than that it is an example of double hy-
drophthalmia, or at least of an enlargement of the eyeball itself.
When we consider the nature of the vascular apparatus of the eye,
and recollect also that in this disease the powers of vision remain
unimpaired, and that the eye shows no symptom of increased
vascularity, we cannot but conclude that the enlargement is
owing to an actual increase in the vitreous and aqueous humours
of the eye. There is not the slightest evidence that the pro-
trusion of the eyeballs is symptomatic of disease of the braina.
Nor can we admit that the protrusion arises from oedema of the
orbital cellular structure, for it is a remarkable fact, that in some
cases of the greatest emaciation, this singular condition becomes
most prominent. This was remarkably seen in the case which I
communicated to Dr. Graves.

The enlargement of the eyes may appear in a sudden manner.
Thus in a case observed by Dr. Adams, the appearance of the
eyes presented nothing remarkable until after a long-continued
fit of coughing and retching. On the following day the symptom
attracted the attention of the lady’s friends.

We may expect that some light will be thrown upon the func-
tions of the thyroid gland by the study of this disease. In speak-
ing of the connexion between bronchocele and affections of the
head, Dr. Parry suggests that the thyroid gland “ is intended in
part to serve as a diverticulum in order to avert from the brain a
part of the blood which, urged with too great force by various
causes, might disorder or destroy the functions of that important
organ.” The fact, long known, of the connexion between the
thyroid gland and the state of the uterine function, should be con-
sidered, and it is to be remembered that in cases of the combina-
tion now before us, Dr. Parry observed not only the increase of
the tumour immediately before, but its subsidence after the men-
strual discharge ; and he has further shown that venesection had
the effect of reducing the swelling of the neck. Finally, some

a The fact of the simultaneous engagement of both eyes and the absence of symp-
toms of abscess of any portion of the brain, to say nothing of the general history of these
cases, is quite conclusive.

296 DISEASES OF THE MUSCULAR STRUCTURES OF THE HEART.

analogy may be found between this condition of the tbyroid gland
and that of the liver, m cases of obstruction or weakness of the
right side of the heart.

The following conclusions appear justifiable in regard to this
peculiar and still obscure affection : —

1. That under certain circumstances the action of the heart
may become permanently excited, as shown by its rapidity, ine-
gularity of action, and increased force; and that this state is at-
tended with three remarkable epiphenomena, namely, the turges-
cence of the thyroid gland, the increased action of the arteries of
the neck, and the enlargement of the eyeballs.

2. That this condition is not attended with fever, or signs or
symptoms of cardiac inflammation, but is more related to func-
tional disturbance.

3. That the disease is most commonly observed in the female,
associated with hysteria, neuralgia, or uterine disturbance ; but that
it may occur with all its characteristic phenomena in the male.

4. That this combination of diseased actions may occur at a
great variety of ages, from puberty upwaids.

5. That it exhibits exacerbations and remissions at various
periods, which appear to depend on the condition of the heart s

action.

6. That the enlargement of the thyroid gland arises quite
independently of the ordinary exciting causes of endemic bron-
cliocclc •

7. That this enlargement is attended with a diastolic pulsa-
tion of the tumour.

8. That in addition to the diastolic throb, there are presented
the usual physical signs of aneurismal varix in the gland.

9. That the existence of these signs, namely, the purring
thrill and murmur, may be general or partial, and also vary in in-
tensity in different parts of the tumour, and at different periods

of the disease. _ . . ,

10. That in the more advanced periods these signs subside

with the increasing solidity of the gland. .... ,

11. That various venous murmurs may exist in the jugu ais,
or in the large veins traversing the tumour, during the progress
of the disease, and even after it has lasted foi yeais.

AFFECTION OF THE nEART AND THYROID GLAND.

297

12. That there is some probability that the sensation termed
the “ Globus Hystericus" may proceed from the temporary exis-
tence of the first stages of this affection.

13. That the increased pulsation of the arteries of the neck
cannot be explained by cardiac regurgitation, or by any determi-
nation of blood to the brain ; nor is it any evidence of general ar-
terial excitement.

14. That under these circumstances the double sound and
impulse are often developed in the carotids.

15. That the enlargement of the eyeballs is not necessarily
attended with any alteration of vision, nor does it appear to pi-e-
dispose the eye to inflammatory disease either of its external co-
vering or internal structures.

16. That this enlargement is variable in amount during the
progress of the case, and that it may subside to a great degree, if
not altogether.

17. That in fatal cases of this affection the morbid conditions
which have been observed are dilatation and hypertrophy of the
heart, enlargement of the inferior thyroid arteries, and dilatation
of the jugular veins.

18. That a mixed case of the disease may be met with, in
which a previously existing bronchocele of the ordinary kind is
influenced by the occurrence of nervous or organic disease of the
heart.

19. That the essence of the disease appears to consist in func-
tional disturbance of the heart, which maybe followed by organic
change.

298

CHAPTER IV.

WEAKNESS OR DEFICIENT MUSCULAR POWER OF THE HEART.

As a weakened state of the heart, no matter from what it may
arise, indicates a certain course to the physician, we shall, even
at the risk of repetition, trace out its most ordinary causes. They
are as follow : —

Weakness of the heart in connexion with muscular atrophy
or emaciation — occurring in the combination of cardiac dilatation
with hepatic and pulmonary disease — as a result in cases of peri-
carditis or endo-pericarditis — in connexion with fatty degenera-
tion of the organ — in fever, independent of softening of the heart —
and, lastly, in connexion with the softening of the organ as a result
of essential fevers, and especially typhus.

We thus see that the weakened condition of the heart may be
presented under various circumstances. Its principal causes, how-
ever, are reducible to two great heads, namely, weakness from
diminished innervation, independent of organic disease, and again,
that debility which is consequent on or associated with organic
change of some kind.

The condition of ordinary syncope is referrible to the first of
these heads ; the completeness of the syncope being in proportion
to the amount of temporary paralysis of the heart. In this con-
dition the loss of contractile power is temporary, but it is proba-
ble that in some diseases a more enduring state of debility of the
heart occurs, yet quite independent of anatomical change in the
organ.

It is still to be determined whether the heart, or any one of
its cavities, is liable to paralysis resulting from a primary lesion
of the nervous centres or the ganglionic system ; or again, whe-
ther obstruction of the coronary arteries can cause a semi-paralyzed
condition, analogous to that which has been already descubcd as
occurring in the extremities from chronic arteritis.

deficient muscular power of the heart. 299

Atrophy of the Heart. — Of atrophy of the heart, considered as
an idiopathic affection, we know little or nothing, nor are we able
to specify any symptom of this condition in cases of general ema-
ciation ; for in chronic tuberculosis of the lung with atrophy of
the heart, no peculiarity of the circulation has been observed.
It is in phthisis that we most often meet with extreme atrophy
of the heart, a condition to be explained by referring to the
diminished amount of circulating fluid on the one hand, and
the process of absorption of the red tissues on the other. In
this way not only the voluntary but the involuntary muscles are
diminished in volume and power, and become pale and flabby, as
is exemplified not only in the heart, but in portions of the diges-
tive and generative systems. To such a degree is this process car-
ried in the stomach, that the organ may resemble a membranous
bag of extreme tenuity, as in the ramollissement avec amincissement
of Louis. Other examples may be given, among which should
be noticed the atrophy of the uterus, under the same general con-
dition, as first described by Professor Montgomery0. In the heart
this process of atrophy is not confined to the muscular structures
alone. The valves may be singularly atrophied and cribriform, as
described by Mr. King, of London, and also by Dr. Adams and
Professor Smith. In a patient who died of phthisis at a very ad-
vanced a^e, and in whom the aortic valves were the seat of the
alteration, I found the filaments corresponding to the perforations
to be as delicate as a spider’s thread.

Dr. Hope states, that in atrophy without any other change in
the organ, the heart generally contracts on itself so as to diminish its
cavities. It is under these circumstances that the heart of an adult
resembles that of a child, a condition described by many authors,
and by no means uncommon. But when in phthisis the fatty de-
generation engages the organ, its volume may be even larger than
natural.

I have seen no example of the production of this atrophy by
excessive bleeding, as mentioned by Laennec, or from the pres-
sure of false membranes, of which a case is given by Bouillaud.

Weakness of the Heart in Pericarditis. — To every one who has

* Dublin Journal of Medical Science, First Series, vol. xxvii. p. 161.

300

DEFICIENT MUSCULAR POWER OF THE HEART.

seen fatal cases of this disease, the condition of the patient for
some time before death appears to indicate that the left ventricle
has lost much of its contractile force. The smallness, irregularity,
and feebleness of the pulse, the coldness of the surface, the pallor
of the countenance, and the frequent tendency to faint, all indicate
extreme weakness of the systemic side of the heart. The symp-
toms in question are supposed by many to arise from the pressure
of the effused fluid, an explanation difficult to be received when
we recollect how little the function of the heart is disturbed in its
dislocations from excentric pressure. It is more than probable
that a condition of the ventricular muscles analogous to that of
the intercostals in advanced cases of empyema does really occur ;
and we may draw a close analogy between the yielding state of
the intercostal muscles in pleurisy and the debility of the cardiac
muscles in pericarditis. In both we have the common condition
of inflammation of a tissue in close connexion with the muscle itself,
and in both we observe, first, the evidences of excitement, and
next, those of depressed vitality of the contiguous muscles. Whe-
ther it be that in these cases inflammation of muscular tissue itself
is associated with that of the serous membrane, is yet to be de-
termined ; but that such is the fact appears not improbable, par-
ticularly as myocarditis has been observed in certain cases of
pericarditis.

It has been already shown that the non-recognition of this
cause of debility of the heart has led to grave errors in the treat-
ment of pericardial inflammation, and that the life of the patient is
often sacrificed by perseverance in an antiphlogistic regimen at a
time when the heart was losing its contractile force, and when sti-
mulation had become necessary. We are still in ignorance of any
direct means by which the first stages of this important change
may be indicated, but the progress of clinical observation will

throw great light on this subject.

It is unlikely that under these circumstances the debility of
the heart can be combated by stimulants with the same success as
in the non-inflam matory softening or the debility in typhus, but its
occurrence should make us suspend antiphlogistic treatment, and
theoretically it indicates stimulation.

According to Ilassc, we may assume that no one form of car-

DEFICIENT MUSCULAR POWER OF THE HEART.

301

ditis can occur in a high degree without implicating more or less
all the textures of the heart. “ We must, however,” he says, “ guard
against confounding with carditis those cases of pericarditis, and
of pleurisy of the left side, in which the substance of the heart is
either flaccid, pale, and softened, or here and there dark-coloured
and pulpy. As well might a diaphragm, softened and discoloured
by inflammation of the superincumbent pleura, be reckoned as in-
flamed. In both instances the influence of the neighbouring in-
flammatory process is too obvious to be called into question”11.

This author has admitted the dynamic origin of the dilatation
of the intercostals and diaphragm in pleurisy, which I long since
demonstrated, and analogy leads us to apply the same reasoning
in the case of pericarditis. It is still to be determined how much
of mere paralysis, and how much of an actual inflammatory state
of the cardiac muscles, concur in the production of the weakened
or flaccid condition.

Weakness of the Heart from Dilatation associated with Pulmo-
nary and Hepatic Disease. — It is only necessary to notice this form
here. Its history has been already given in the preceding pages.

We shall now proceed, in a separate chapter, to examine those
cases of weakness of the heart which proceed from the fatty de-
generation of the organ ; after which, that important form of weak-
ness of the heart so commonly met with as a secondary disease in
the essential fevers of this country may be studied with advan-
tage. This inquiry, however, refers to a special condition, and
we shall not enter upon it until the general treatment of the or-
ganic diseases of the heart has been discussed.

* Ilasse, Pathological Anatomy, Swaine’s Translation, p. 201.

302

CHAPTER V.

ON FATTY DEGENERATION OF THE HEART.

The accumulation of fat upon the surface or in the substance
of the heart has long been recognised. But it is only within our
own time that the subject was properly examined. Laennec,
who has been followed by Hope and by Hasse, describes two
forms of the affection; and though his account of the disease is
but meagre, the researches of subsequent observers, including Ro-
kitansky, have not established any case that may not be referred
to either of his varieties.

In one form, fat is deposited more or less abundantly in the
subserous cellular membrane, so as to produce a layer of fat en-
veloping the heart. Its thickness is variable, and its distribution
generally most abundant over the right cavities. The muscular
structure is as it were pushed before it, and commonly found pale,
softened, and wasted. According to Hasse, the fat globules collect
not only within the compartments of the subserous cellular tissue,
but are freely deposited within the muscular substance, and even
between its primitive fibres.

The colour of this deposit is generally yellow ; and in extreme
cases, on the sternum being raised, the heart appears as if it were
jaundiced.

In the second variety, the adipose degeneration is supposed to
commence in the muscular structure, and to be a true transforma-
tion. Rokitansky states, that in this condition the fat does not
accumulate in masses, there being no fat globules included within
fasciculi of cellular tissue, but it is beaded in minute microscopic
granules, closely interlaced and imbedded among the primitive
fibres of the heart’s muscles. These have lost their transverse
striae ; the fibrils arc friable and easily reduced to minute mole-
cules11. This condition affects the left, perhaps, more than the right

1 Hasse, Pathological Anatomy, Dr. Swaine’s Translation, p. 170.

FATTY DEGENERATION OF THE HEART. 303

ventricle, and is generally thought to be the most common cause
of spontaneous rupture of the heart.

Can we in the present state of our knowledge declare that a
strong line of distinction exists between these forms ? I apprehend
not, and think that at least the first form may induce the second.
With both these forms, such as Rokitansky has described, the pa-
thologists of Dublin have long been familiar, and excellent spe-
cimens of the conditions in question exist in our museums. In
the collection at the Park-street School there was a remarkable
example of rupture of the left ventricle ; the entire heart being so
changed that it was barely possible to trace any muscular fibre
in it. The form of the organ remained unaltered, but so great
was the disappearance of the muscle that it is difficult to under-
stand how circulation could have been carried on.

Rokitansky is of opinion that this change occurs in hypertro-
phied hearts, which exhibit the signs of a former endocarditis and
carditis. IIow far the previous existence of inflammation may
have predisposed to the affection is still to be determined ; but
that the affection may occur without evidence of valvular or peri-
cardial disease seems established by the case published by Dr.
Cheyne.

If, however, we look on this matter in a practical point of
view, we find that the general symptoms and history in both forms
of the affection are much the same. It is very probable, how-
ever, that the chance of rupture of the heart is greater in the
second than the first form.

Let us now examine some of the cases which have been ob-
served in Dublin.

Case XXVII. — Fatty Degeneration of both Ventricles, with steato-
matous and earthy Deposits in the Aorta; Pulse irregular and
intermittent; Death by Apoplexy.

This case is given by Dr. Cheynea: — A gentleman, aged 60,
who had lived a sedentary life and indulged freely at the table,
became subject to gout in the feet. His regular gout subsided,
and he suffered from oedema of the ankles in the evening,' for

Dublin Hospital Reports, vol. ii. p. 217.

304

FATTY DEGENERATION OF THE HEART.

two or three years before his death. His pulse was occasion-
ally intermitting. On the 3rd of February, 1816, he returned
home much exhausted by a long walk, and suffering from a flut-
tering or palpitation of the heart. This was relieved by wine.
In the evening he was attacked by a severe fit of coughing, and
fell insensible. No paralysis followed this attack, but the patient
was pale and confused. The pulse was extremely irregular and
unequal. Bleeding and purgatives were freely used, followed by
mercurials and diuretics, as the secretion of the kidneys was
scanty. The lungs, however, became more loaded, and anasarca
rapidly increased. On the 10th of April he was found in bed
flushed, speechless, and hemiplegic. The paralysis remained up
to the period of his death.

The only peculiarity in the last period of his illness, which
lasted only eight or nine days, was in the state of the respiration.
For several days his breathing was irregular; it would entirely
cease for a quarter of a minute, then it would become perceptible,
though very low, then by degrees it became heaving and quick,
and then it would gradually cease again. This revolution in the
state of his breathing occupied about a minute, during which
there were about thirty acts of respiration.

On dissection the brain presented nothing very remarkable,
except an increased vascularity of the pia mater, particularly over
the middle and posterior lobes of the cerebrum, llie ventricles
contained three or four ounces of fluid. Fhe pericardium con-
tained two ounces of fluid, and the heart was three times its na-
tural size. The lower part of the right ventricle was converted
into a soft, fatty substance ; the upper part was remarkably thin,
and it gradually degenerated into this soft, fatty condition. The
cavity of the left ventricle was greatly enlarged, and its whole
substance, with the exception of the internal reticulated structure
and carnere columme, was converted into fat. The valves were
sound, and the aorta studded with steatomatous and earthy con-
cretions.

This case is full of instruction. We see in a patient ofseden-
tary'and luxurious habits the development of the gouty condition,
and consequent on this the establishment of a weakened heart, as
shown by the irregularity of the pulse and the tendency to oedema.

FATTY DEGENERATION OF THE HEART.

305

After an over-exerdon the fluttering sensation about the heart
is suddenly increased, and at the time relieved by the use of wine,
and this is followed by an apoplectic seizure, from which recovery
takes place without any paralysis. The patient is largely depleted,
debarred from his usual stimuli, and dropsy sets in, with increased
irregularity of the pulse. Another apoplectic attack, this time
followed by hemiplegia, occurs, and the patient sinks, after exhi-
biting a peculiar character of respiration, doubtless a symptom of
this condition of the heart. Dissection shows nothing but conges-
tion of the brain, and a nearly complete degeneration of the heart
into fat.

That a different line of treatment, at least with reference to
the detraction of blood and the withdrawal of stimuli, would have
been adopted by Dr. Cheyne if this case had occurred some years
later, no one can doubt. Owing to the observations of Dr. Adams,
the weakened state of the heart is now considered as the cause of
the apoplectic seizures, and hence physicians are more cautious
in reducing the system.

The next case is abridged from Dr. Adams’s Memoir, pub-
lished in 1827\ It is one of great interest, being, in truth, the
key to our knowledge of the subject, and having the same relation
to the diagnosis of fatty heart that the case of aneurism by Dr.
Beatty bears to that of aneurism of the abdominal aortab.

Case XXVIII. — Repeated Apoplectic Attacks during a long series

of years; Absence of Paralysis; Remarkable slowness of Pulse ;

Fatty degeneration of both Ventricles , especially the right.

“An officer in the revenue, aged 68 years, of a full habit of
body, had for a long time been incapable of any exertion, as he
was subject to oppression of his breathing and continued cough.
In May, 1819, in conjunction with his ordinary medical atten-
dant, Mr. Duggan, I saw this gentleman: he was just then reco-
vering from the effects of an apoplectic attack which had suddenly
seized him three days before. He was well enough to be about
his house, and even to go out. But he was oppressed by stupor,
having a constant disposition to sleep, and still a very troublesome
cough. What most attracted my attention w'as the irregularity

“ Dublin Hospital Reports, vol. iv. *> Ibid. vol. v,

VOL. I.

306

FATTY DEGENERATION OF THE HEART.

of his breathing, and remarkable slowness of the pulse, which ge-
nerally ranged at the rate ot 30 in a minute. Mr. Duggan in-
formed me that he had been in almost continual attendance on
this gentleman for the last seven years, and that during that pe-
riod he had seen him, he is quite certain, in not less than twenty
apoplectic attacks. Before each of them he was observed, for a
day or two, heavy and lethargic, with loss of memory. He would
then fall down in a state of complete insensibility, and was on se-
veral occasions hurt by the fall. When they attacked him, his
pulse would become even slower than usual, his breathing loudly
stertorous. He was bled without loss of time, and the most active
purgative medicines were exhibited. As a preventive measuie,
a large issue was inserted in the neck, and a spare legimen was
directed for him. He recovered from these attacks without any
paralysis. CEdema of the feet and ankles came on early in Decem-
ber ; his cough became more urgent, and his breathing more op-
pressed ; his faculties, too, became weakei.

“November 4th, 1819, he was suddenly seized with an apo-
plectic attack, which in two hours carried him off, before the arrival
of his medical attendant.

“ Dissection 56 hours after death. — The dura mater presented
a natural appearance. The arachnoid membrane was separated
from the pia mater by a fluid of gelatinous appearance. The sub-
stance of the brain was watery and of a yellowish white colour.
There was some water in the ventricles. These cavities did not
appear enlarged, but the foramen of communication between them
was dilated. The coats of the carotid and middle arteries of the
dura mater were quite white and opaque from bony deposition,
but were pervious.

“ The right lung was sound; the left was compressed, and ad-
hered to the side of the thorax: about a pint of serum and quan-
tities of soft fat, of a very deep yellow colour, filled up the space
between the anterior mediastinum and the compressed lung, which
was impervious to air, and must have been totally useless.

“ The right auricle of the heart was much dilated, ihe right
ventricle externally presented no appearance whatever of muscu-
lar fibres; it seemed composed of fat through almost its whole
substance, of the same deep yellow colour as that which occupied
the place of the left lung. The reticulated lining of the ventucle,

FATTY DEGENERATION OF THE HEART.

307

which here and there allowed the fat to appear between its fibres,
alone presented any appearance of muscular structure.

“ The left ventricle was very thin, and its whole surface was
covered with a layer of fat. Beneath this tlje muscular structure
was not a line in thickness ; it had degenerated from its natural
state ; was soft, and easily torn, and a section of it exhibited more
the appearance of liver than of a heart. The septum of the ven-
tricles presented the same appearance. In both ventricles, even
in the lining fibres, yellow spots, where fat had occupied the
place of muscular structure, were to be observed. The whole or-
gan was remarkably light ; the valves were all sound, except those
of the aorta, which were studded with specks of bone, but else-
where were cartilaginous and elastic, from which they derived a
disposition to remain closed; a fluid gently injected from the ven-
tricle would pass them ; still, when the heart was reversed and
water poured from the ventricle upon them, their valves retained
it; its weight was not sufficient to separate the edges of the
thickened valves. There was much fluid blood contained in the
heart.

“ The liver was natural; the vena porta was unusually dis-
tended. The spleen was healthy in its structure, although en-
larged ; the other viscera presented nothing unusual.”

In the memoir from which the above is extracted is given the
particulars of another case, which, so far as I am aware, is without
parallel in the records of medicine. It is that of a physician
who during the last ten years of his life had suffered from repeated
and sudden attacks of syncope, which, however, differed from
ordinary fainting in the circumstances that the attack came on
m a most sudden and unexpected manner, and in the same way
went oft, leaving no unpleasant effect. His age was 68, when he
was suddenly attacked with symptoms resembling those of an-
gina pectoris. He had severe pain in the chest, extending down
the right arm, and attended with numbness. There was dimness
of vision and rapid vertigo, but he did not faint. From that mo-
ment his breathing became oppressed, and he discovered that the
pulse , which was unaccountably weak in the left arm, had altogether
disappeared from the right.

This patient lived for six weeks, suffering from difficult respi-

x 2

308

FATTY DEGENERATION OF THE HEART.

ration and declining strength, yet during the whole of this time
the most careful examination f ailed to discover any pulse in any artery
of the body. The action of the heart was not sensible to the hand,
and on the application of the ear an obscure undulating sensation
was all that could be observed. Dissection showed some recent pleu-
ritis of the right side; the lungs were healthy ; the heart was large,
flabby, and of a yellow colour, from fatty deposition. All the ca-
vities were distended with fluid blood; the semilunar valves and
the aorta were completely ossified ; but the bony or earthy depo-
sition was not confined to the aorta ; it extended to the coronary
arteries, which were so completely converted into bone as to be
quite solid, having no perceptible cavity except at the distance of
an inch from their origin.

In explaining the extraordinary phenomena in this case, Mr.
Adams leans strongly to the opinion that they are to be attributed
to a more or less paralyzed state of the heart, resulting from the
obstruction of the coronary vessels. The suddenness of the failure
of the pulse is most remarkable ; and that it was connected more
with the weakness of the heart than the condition of the aortic
valves is obvious, when we consider the symptoms of valvular
obstruction, and the fact that the sounds of the heart were so
singularly diminished, that to many it was doubtful whether its
action could be discovered.

I have introduced this case here because that, with all its pe-
culiarities, it comes into the category of weak hearts connected
with fatty degeneration. It will be recollected that the heart
was yellow from fatty depositions, and we shall presently see that
an atheromatous or bony deposit in the aorta is a not infrequent
complication of this affection. The same condition, extended
to the coronary arteries, may have been the last step in the mor-
bid processes in this case, and a semi-paralyzed state of the al-
ready weakened heart the immediate result.

A comparison of this case with that which Dr. Graves and I
have given, of paralysis of the right lower extremity resulting
from arterial obstruction, which apparently commenced in por-
tions of the vessel not the farthest removed from the centre11,

» Dublin Hospital Reports, vol. v. Report of the Meath Hospital.

FATTY DEGENERATION OF TIIE HEART.

309

strongly corroborates the views that Dr. Adams has taken of
the cause of failure of the heart’s action, which in all probability
was the more easily induced by the previously weakened state of
the organ.

The next observer of this disease is Professor Smith, who has
enriched our knowledge of the subject by his discovery of free
oil in the blood, and by his observations on the production of air
in the heart and veins after deatha.

This author details the appearances on dissection in two cases.
In one the immediate cause of death was rupture of the left ven-
tricle. Both these cases were examples of the first form of fatty
degeneration, or that in which the fatty matter seems primarily
deposited on the surface of the heart.

Case XXIX. — Fatty condition of the Heart; Rupture of the left
Ventricle; Free Oil in the Blood.

“ Margaret Newman, aged 90, died suddenly, having pre-
viously complained merely of debility and the infirmities that ‘ wait
on age.’

“ Inspection twelve hours after death. — The integuments cover-
ing the arms, thighs, and chest, presented large livid patches,
and a crepitation was felt in the subcutaneous cellular tissue over
almost all parts of the body, but particularly beneath the disco-
loured portions of the skin : the subcutaneous cellular tissue was
likewise loaded with adipose substance of an unhealthy softness,
pale, and watery. Upon elevating the sternum, air was seen in
the cellular tissue of the mediastinum ; the pericardium was dis-
tended to the utmost, with blood partly fluid, partly in clots; the
heart, thickly covered with adeps, particularly upon its posterior
surface, was soft, pale, and flaccid, and globules of air were seen
beneath its serous covering, arranged for the most part along the
course of the coronary vessels.

“ Near the centre of the anterior part of the left ventricle,
there was a small lacerated opening, about a quarter of an inch in
length : the substance of the ventricle was softened, most easily
broken by the finger, and of a pale yellowish colour, as if infil-

a Contributions to Pathological Anatomy. By R. W. Smith, A. M. Dublin Journal
of Medical Science, First Series, vol.ix. p. 411.

310

FATTY DEGENERATION OF THE HEART.

trated with purulent matter; the scalpel was greased in cutting
the muscular substance, and upon the surface of the blood which
had escaped from the divided vessels there floated numerous glo-
bules of oil.

“ The abdominal viscera presented remarkable appearances:
beneath the serous investment of the stomach, intestines, liver,
spleen, and kidneys, air was extensively diffused; the liver was
converted into a semifluid pulp, so much so that a stream of water
poured upon it from a moderate height washed away the sub-
stance of the organ, the vascular structure alone being left ; through
this disorganized tissue air and oil were diffused; the spleen and
kidneys presented similar appearances to the liver, and all these
viscera, along with the stomach and heart, floated perfectly in wa-
ter. Upon removing the liver from the body, the division of the
vena cava gave exit to nearly a table-spoonful of a clear, peifectly
transparent, limpid oil, followed by the blood of the vein. I col-
lected about half-an-ounce of oil from what had escaped from the
different organs ; but nearly double the quantity might have been
procured ; several of the larger arteries were ossified ; the brain
presented no morbid appearance. ’

Case XXX.— Fatty condition of the Heart; Free Oil in the Blood.

“A woman, aged 70, waS admitted into the Richmond Hos-
pital, having been found in the street, lying exposed to the wet
and cold, and bearing the appearances of extreme poverty ; she
died about an hour after her admission.

“ Inspection eighteen hours after death. — In the chest a consi-
derable quantity of fluid occupied the cavity of the pleura, upon
either side ; the heart was remarkably soft, pale, and flaccid ; its
substance most easily broken, and its surface covered with a layer
of fat, a quarter of an inch in depth ; the parietes of the ventricles
were thin; the surface of the blood was thickly covered with glo-
bules of limpid oil ; the blood itself was thin, unhealthy in appear-
ance, and without any disposition to coagulate; the vessels of the
brain were greatly congested; the abdominal viscera healthy”

It will be proper, when we take a general view of the symp-
toms and history of this change in the heart’s condition, to discuss
the views of its general pathology which Dr. Smith has advanced

FATTY DEGENERATION OF THE HEART.

311

iii connexion with these cases. Let us, in the meantime, conti-
nue our examination of the cases observed in Dublin.

Case XXXI. — Long-continued Palpitation; Occasional and sud-
den Paintings; Sudden Death , with Apoplectic Symptoms ; Ex-
tensive Fatty Deposits in the Heart.

This case excited great interest in Dublin, and was commu-
nicated to the Pathological Society by Mr. Carmichael in the
Session of 1840. The patient, a clergyman, of upwards of sixty
years of age, and of temperate habits, had generally enjoyed good
health, and had suffered no inconvenience from any symptom re-
ferrible to the heart, to such a degree as to coniine him to his bed,
or prevent him discharging his professional avocations. For
many years, however, he had been subject to palpitations of the
heart ; and on one or two occasions he fainted without any assign-
able cause. The tendency to faint was on several occasions re-
moved by the use of a small quantity of brandy or other stimu-
lants. On the morning of his death he had performed the mar-
riage ceremony between two members of his congregation, and
was sitting at the wedding-breakfast when his head drooped, his
breathing became stertorous, and in a few moments he was dead.
The veins of the neck were turgid, and Dr. Hutton, who was pre-
sent, opened the jugular vein, and tried every other means of
resucitation, but in vain. On the day following his death, the
veins of the forehead became turgid, and yielded a sense of cre-
pitation ; and it was subsequently difficult to convince the friends
of the deceased that he was actually dead, so much did the injec-
tion of the superficial vessels and the colour of the face simulate
life. Dissection was performed five days after death. The cellu-
lar structure of the neck, upper extremities, trunk, and scrotum, was
emphysematous. The scrotum had attained the size of a melon,
and was almost transparent. Much fat existed under the abdomi-
nal integuments and in the anterior mediastinum.

The heart, covered with fat, was found with its right cavities
greatly distended with air. The wall of the right ventricle was
about two lines in thickness, and the muscle seemed nearly re-
placed by fat. What remained of muscle was greasy and friable.
The left cavities presented similar appearances, though not to so
great a degree. The liver, lungs, and brain were healthy.

312'

FATTY DEGENERATION OF THE HEART.

In this case the turgescence of the veins observed at the time
of death seems to favour the opinion of Dr. Adams, that death
may in this disease be produced by venous congestion of the
brain. This view was adopted by Mr. Carmichael, who considered
that from the inability of the right ventricle to propel the blood
through the lungs, the descending cava and veins of the head had
become so overloaded that death was the result. He suggested
that one small bleeding, followed by stimulants, should be the
proper course in such attacks.

The remarkable turgescence of the subcutaneous veins giving,
as in this case, the fallacious appearances of returning animation,
has been well explained by Professor Smith. He refers it to the
production of air, not only in the right side of the heart, but in the
venous system generally, a change which takes place soon after
death; and which produces the injection of the capillaries and
veins of the surface.

The two following cases occurred under my own observation.

Case XXXII. — Anaemic condition ; Very slow Pulse, with valvular
Murmur ; Death, apparently from Syncope; Fatty Degeneration
of the Heart, icith Disease of the Aortic Orifice.

A man, upwards of fifty years of age, was admitted, present-
ing much of the general characteristics of senile phthisis. His
skm was of a pale yellowish tint, and his whole appearance indi-
cated great debility. He complained of cough and dyspnoea, but
did not refer any of his sufferings to the region of the heart. His
pulse was generally 35 in the minute, though occasionally rising
to 40. The action of the heart was regular, but feeble, and a
valvular murmur with the first sound, precisely similar to that in
mitral valve regurgitation, was always audible. This became
louder on ascending the sternum, and was most intense on the
right side, at the articulation of the second rib. We were inclined
to consider this as an example of mitral valve disease, and sup-
posed at first that the aortic murmur might result from anaemia.
The patient died without any struggle. On dissection, the mitral
valves were found healthy. The aortic valves were thickened and
narrowed, but not permanently patent. Water poured into the
aorta did not pass into the ventricle ; the heart was soft and flabby,
and, though not an example of complete fatty degeneration was

FATTY DEGENERATION OF THE HEART.

313

covered by a very thick adipose layer. The aorta presented se-
veral atheromatous patches.

In this case the second sound remained normal ; there was no
regurgitation into the ventricle. The valves were sufficiently dis-
eased to cause a murmur with the first sound, but from their power
of closing completely, the second was unaltered.

Case XXXIII. — Repeated pseudo- apoplectic attacks , not followed

by Paralysis; Slow Pulse , with valvular Murmur , propagated

into the Aorta.

Edmund Butler, aged sixty-eight, was admitted into the Meath
Hospital, February 9th, 1846. He stated that his health had been
robust until about three years ago, at which time he was suddenly
seized with a fainting fit, in which he would have fallen if he had
not been supported. This occurred several times during the
day, and always left him without any unpleasant effects. Since
that time he has never been free from these attacks for any consi-
derable length of time, and has had at least fifty such seizures.
They are uncertain as to the period of their invasion, and very
irregular as to their intensity, some being much milder and of
shorter duration than others. They are induced by any circum-
stance tending to impede or oppress the heart’s action, such as sud-
den exertion, distended stomach, or constipated bowels. There
is little warning given of the approaching attack. He feels, he
says, a lump first in the stomach, which passes up through the
right side of the neck into the head, where it seems to explode
and pass away with a loud noise resembling thunder, by which
he is stupified. This is often accompanied by a fluttering sensa-
tion about the heart. He never was convulsed or had frothing at
the mouth during the fit, but has occasionally injured his tongue.
The duration of the attack is seldom more than four or five mi-
nutes, and sometimes less ; but during that time he is perfectly
insensible. He suffered no unpleasant effects after the fits, nor
had anything like paralysis. His last fit occurred about one month
before admission. He has never heard it remarked that there
was anything peculiar about his heart or pulse. At first he found
that ardent spirits were the best restorative or prophylactic, but
latterly he has not used them.

314

FATTY DEGENERATION OF THE HEART.

On admission, lie was haggard and emaciated, but seemed the
wreck of what was once a fine, robust man. He lay generally in
a half drowsy state, but when spoken to was perfectly lively and
intelligent.

He makes no complaint of his general health ; his appetite is
good, and he sleeps well; bowels regular, and the urinary func-
tions are in good order. He has, however, some cough, attended
with a slight mucous expectoration. His intellectual powers are
perfect. He complains of a feeling of chilliness over the body,
and is never warm except when close to the fire. This has long
been the case ; and every day he gets a chill, generally in the af-
ternoon, which is followed by increased heat of the surface, but
without sweating.

On percussion, the chest is universally resonant. The respi-
ratory murmur loud, and combined, more especially posteriorly,
with large mucous rales. The impulse of the heart is extremely
slow, and of a dull, prolonged, heaving character, giving the idea
of feeble as well as of slow action. The first sound is accompa-
nied by a soft bellows murmur, which is prolonged into the
commencement of the second sound, and is heard very distinctly
along the sternum, and even in the carotid arteries. The se-
cond sound is also imperfect, though very slightly so ; the imper-
fection being much more evident after some Teats than others.
Pulse 28 in the minute, of a prolonged, sluggish character; the
arteries pulsate visibly all over the body, but no murmur is audible
in them. They appear to be in a state of permanent distention :
the temporal arteries ramifying under the scalp, just as they are
seen in a well-injected subject. All the other cavities and viscera
appear to be in a perfectly healthy state. Urine neither acid nor
alkaline; of a light colour and clear; specific gravity, 1010; it
does not afford a precipitate with nitric acid. He was oideied
wine, and a liniment for the shouldei.

February 17th. The pulse has varied from 28 to 30 in the
minute. The cardiac murmurs continue unchanged ; that with
the first sound is plainly audible over the upper part of the tho-
rax, but is most evident along the course of the aorta.

His aspect and general health are greatly improved since his
admission. He gets up every day, and is much stronger. The

FATTY DEGENERATION OF THE HEART.

315

shoulder is almost quite well. The pulse has continued at about
28 or 30. He says he has had two threatenings of fits since his
admission, both occurring in bed, and both warded off by a pecu-
liar manoeuvre: as soon as he perceives symptoms of the approaching
attack , he directly turns on his hands and knees, keeping his head low,
and by this means, he says, he often averts what othenuise would end
in an attack.

We remarked to-day, on listening attentively to the heart’s
action, that there were occasional sertii-beats between the regular
contractions, very weak, unattended with impulse, and correspond-
ing to a similar state of the pulse, which thus probably amounts
to about 36 in the minute, the evident beats being only 28, so that
there must be about eight of these semi-beats in the minute ; — but
these signs are very indistinct.

18th. He complains to-day of palpitation, and a feeling of un-
easiness about the heart ; — the impulse is increased and is found
to consist of two distinct pulsations. The murmur with the first
sound is somewhat louder than before. On listening attentively,
there are heard occasional abortive attempts at a contraction, pro-
bably about four in the minute. They do not destroy the regular
intervals between the stronger sounds, but are heard, as it were,
filling up the interval. We could not recognise a corresponding
state of the pulse, which counted 32 in the minute.

In about three months this patient was again admitted into
hospital. The cardiac phenomena remained as before, but a new
symptom appeared, namely, a remarkable pulsation in the right
jugular vein. This was most evident when the patient lay down.
The number of the reflex pulsations was difficult to be established,
but they were more than double the number of the manifest ven-
tricular contractions. About every third pulsation was strong and
sudden, and could be seen at a distance ; the remaining waves
were much less distinct, and some very minor ones could be per-
ceived. These may have possibly corresponded with those im-
perfect contractions already noticed in the heart. The appearance
of this patient’s neck was very singular, and the pulsation of the
veins such as we never before witnessed.

He has had scarcely any of the cardiac attacks since he was
discharged; he referred the premonitory sensations to the right

316

FATTY DEGENERATION OF THE HEART.

supra-clavicular region, but stated tliat lie often experienced them
without loss of consciousness having followed.

In a clinical point of view, we may separate cases of fatty
disease of the heart into two classes. In the one the alteration is
found in various degrees of development, although other organs
than the heart have been prominently affected ; in the other, the
heart affection seems the principal lesion, and the general health
continues good. In some of the first class the symptoms may he
so modified by the cardiac disease as to lead to the latter being
suspected during life, yet in others the condition of the heart
is only recognised on dissection, or, it may be, microscopic exa-
mination. The memoirs of Dr. Ormerod and of Dr. Quain con-
tain numerous examples of this kind, and show that in many
chronic diseases this condition of the heart is in progress, although
its existence is commonly overlooked or unsuspected.

In this way the disease is met associated with phthisis — with
bronchial disease— chronic affections of the liver and kidneys—
diseased prostate gland, chronic rheumatism, and under various
conditions of the gouty state. In other cases, too, this lesion may
exist, though not to such a degree as to draw special attention.
And ’it is, doubtless, the cause why so many patients labouring
under various chronic affections sink rapidly when placed on a
restricted regimen, or when kept too much under the influence of
lowering medicines. The recognition of this class of cases is,
perhaps, of mure importance than that in which the disease is

prominent, and, as it were, isolated. _ .

We owe not only the statement but the best illustrations ol
this important clinical fact to Dr. Ormerod, whose memoir is of
great value*, not only as to the history of the disease, but its

« Observations on the Clinical History and Pathology of one form of Fatty Degene-
ration of the Heart. London Medical Gazette, vol. ix. p. / 39.

The researches of Drs. Paget, Ormerod and Quain, of Hasse, and other pathological
anatomists have given us full information as to the microscopical appearances m tins dis-
ease. But as the account given by Dr. Ormerod is the most succinct and best adapted

to trive a proper idea of the affection, I shall quote it here.

“ To the unassisted eye,” says Dr. Ormerod, “ the muscular substance of a healthy
heart presents characters distinguishing it from ordinary muscular tissue; for it is more
compadTd homogeneous, and not loosely divided into bundles of fibres, as is ordinary
muscle Under the microscope it also presents some striking differences the transverse

strise being less distinctly marked, and the fibres having a singularly granular appearance.

FATTY DEGENERATION OF THE HEART.

317

microscopic anatomy. And he has shown that without the em-
ployment of the microscope it will not be safe to assert that the

It is very important to notice this normal difference at the outset ; for the first step to-
wards fatty degeneration consists in the loss of the continuity of the transverse striae, and
in the increase of this granular marking of the fibres, which would seem to be in some
degree their normal appearance.

“ This is the first step, and, as wholly undiscoverable by the naked eye, may often
pass unnoticed, unless something in the symptoms, or some change in the general condi-
tion of the heart, call particular attention to that organ. Such conditions may be a small,
pale, flabby, state of the heart, not inaptly compared to the colour of withered leaves, and
to the feel of a moist glove. But such are not commonly the signs which call attention
to the existence of this structural change ; they are ordinarily much more obvious.

“ On opening a heart thus affected, the interior of the ventricles appears to be mottled
over with buff-coloured spots of a singular zigzag form. The same may be noticed be-
neath the pericardium also ; and, in extreme cases, the same appearance is found, on sec-
tion, to pervade the whole thickness of the walls of the ventricle and of the camese
columns. Of these latter, the musculi papillares seem most liable to be affected ; not
to say that this form of disease never occurs in the walls of the auricles, — at least I have
never seen it there.

“ Microscopic examination reveals the nature of these spots : they are not deposits,
but distinctly degenerated muscular fibres. The outline, not merely of the masses, but of
each single fibril, is accurately preserved. Instead, however, of transverse stria: and nu-
clei, the evidences of active vitality, there is little to be seen but a congeries of oil globules.
The whole history of the degeneration may be traced in one of these little spots. JFirst,
from the immediate neighbourhood of the spot we may obtain healthy musculat fibre ;
then the transverse striae become less distinct, they are rows of dots rather than conti-
nuous lines ; then the intervals between the dots become wider, and the dots themselves
run into longitudinal rather than transverse lines ; and then all the regularity is lost, and
the dots appear to stud the surface all over, like the points on a bit of fish-skin. Probably
long before this time the fibre has lost all its properties as a muscle ; but there are further
changes to observe ; for now, mixed with these minute dots, are to be seen small oil glo-
bules, which increase and coalesce till the fibril presents little else but a congeries of oil
drops contained within the sarcolemma.

“ This is not the only change which the fibres undergo ; for, with whatever care they
are disintegrated, they are found to be short, and as if unusually brittle, — a general con-
dition which may, perhaps, be of more serious importance than the actual fatty degenera-
tion of the organ.

“ Such are the most common features of the disease, and sufficiently obvious when
really once noticed, to prevent their being readily overlooked afterwards. But we must
not rely too exclusively upon them ; for, as already observed, in the absence of these
little spots marking the extreme degree of fatty degeneration in single points, the disease
may have pervaded the whole substance of the heart ; and the recognition of such a
change will be difficult in exact proportion to its extent, and, therefore, its importance,
from the want of healthy tissue wherewith to contrast the diseased fibres. And there is
no solution for the difficulty except in the use of the microscope, whose information, should
anything casually induce us to solicit it on this subject, at least is infallible.”

318

FATTY DEGENERATION OF THE HEART.

heart is free from this disease. Besides giving examples of the
affection in its well-developed and manifest form, he has recorded
cases of various degrees of the fatty change in the following dis-
eases : — delirium tremens; paraplegia; dropsy; hydrothorax;
bronchitis ; marasmus ; epistaxis ; haemorrhage from placenta prse-
via; acute and chronic phthisis; valvular disease; encephaloid
disease of the pericardium ; renal disease ; pneumonia ; apoplexy ;
and fever. Of these facts the practitioner should take especial
note, not that he is to believe that the fatty state of the heart was
the cause of these various maladies, or produced by them, but
that it is a frequent, most important, and often latent complica-
tion in chronic disease ; and it behoves him to make this know-
ledge available in his treatment and prognosis.

He must bear in mind that in many chronic cases, even al-
though there be no symptom or well-marked sign to draw atten-
tion to the heart, yet that it may be more or less affected with this
disease ; and that although the circulation appears to be carried
on with a fair amount of strength, yet that the muscular fibres of
the heart may be atrophied, and under these circumstances liable
to a sudden failure of action.

In the treatment, then, of many chronic affections, and, above
all, in that of acute irritations supervening upon chronic disease
of any kind, or occurring in persons past the prime' of life, or
again, in younger patients whose systems have been, from what-
ever cause, debilitated, it becomes necessary to take the state of
the heart into consideration, and by every means in our power
to determine how far its vital and organic conditions have been
affected ; for there is no class of patients in which a depraved haa-
matosis has occurred, from deficient innervation or nutrition, on
the one hand, or from excess of nutrition, on the other, that is not
liable to the disease.

We may inquire whether this disease is to be considered
as a primary local lesion, or one secondary to certain changes in
the blood itself. Without going into nice distinctions, but look-
ing at the matter practically, we may believe that both forms of
fatty disease, namely, the growth of fat upon the organ, and the
original degeneration of the muscular fibre itself, are to be re-
ferred to general conditions of the system. The first form is the

FATTY DEGENERATION OF THE HEART.

319

result of circumstances which favour the formation of fat, while
its amount is still within the limits of health; and the second,
or the fatty transformation, is commonly met associated with fatty
disease in other parts, and may be safely held as secondary to a
general condition. Dr. Quain believes “ that the molecular fatty
matter in the fibre is the result of a chemical or physical change
in the composition of the muscle itself, independent of those pro-
cesses which we call vital”a.

Reasoning from facts observed with reference to the formation
of adipocire in dead animal matter, this author comes to the con-
clusion that when the protein compounds, albumen and librine,
are placed in a position unfavourable to their organization, or
when they enter into the composition of tissues whose organization
or vitality is imperfect, they themselves degenerate and pass into
fatty matter. The change, according to him, is chemical, and is
induced by whatever tends to weaken those vital powers which
preside over the nutrition of the organ. This opinion seems to
have been hinted at by Rokitansky.

But what is the immediate cause of this deficient innervation
of the heart? This question is of importance if we consider the
affection as a local one. Dr. Quain holds that obstruction of the
coronary arteries is common in this affection ; and, without affirm-
ing or denying this proposition, we may believe that this lesion
might produce the disease. Yet examples are to be met with of
fatty heart in which no such condition exists. And the question
arises — Was the disease of the arteries but one of that series of
changes which induced the general disease of the heart? Again,
ossification of both the coronary arteries may exist, and yet the
muscular structure be found not only without atrophy, but red,
firm, and in all respects healthy ; nay, further, the left ventricle
may be hypertrophied, as in cases where the orifice of the aorta
is permanently patent, while the coronary arteries are obstructed.
The occurrence of fatty heart, as a sequel to pericarditis and en-
docarditis, is noticed both by Dr. Williams and by Rokitansky ;
and it is probable that this form may be the best example of the
disease occurring as a local affection. In the case of pericar-

“ On Fatty Disease of the Heart. By Richard Quain, M.D. Medico Chirurgical
Transactions, vol. xxxiii. p. 140. ,

320

FATTY DEGENERATION OF THE HEART.

ditis, two circumstances would favour its development. There
is probably a case in which the plastic matter takes on the fatty
transformation, so as to cover the heart with a layer of fat, which
subsequently increases under the law of elective affinity. Again,
it may be that from the effect of the adhesion, atrophy and dege-
neration of the muscular fibre are produced ; thus both forms of
fatty heart may occur in the same individual, and the case be
originally an example of local disease.

I have already spoken of the effect of adherent pericardium in
producing atrophy of the heart. But in disease, many paths con-
duct to the same end ; and the duty of the physician is, first, to
learn the mode of recognising the affection, no matter how pro-
duced, and next, to ascertain its various causes. So far back as
1836, Professor Smith showed that, in certain cases of fatty heart,
free and limpid oil existed in large quantities in the blood, a con-
dition in which, as might be expected, other organs besides the
heart were found degenerated. This appears to prove that a fatty
state of the heart may be caused not alone by degeneration of the
protein compounds, but also from oil already formed and circu-
lating in the blood itself.

GENERAL DIAGNOSIS OF THE DISEASE.

If it be inquired how far we have gone, since the time of
Laennec, in establishing the diagnosis of this affection, it will ap-
pear that as yet but little has been done. Laennec declared tliat
lie knew of no means by which the diagnosis of fatty degenera-
tion of the heart could be made ; and Dr. Ormerod, writing in
1849, observes, that “ the most extreme cases detailed may show
that the diagnosis on general or physical grounds is almost im-
possible.” “ We cannot,” he says in another place, “ predict with
certainty in any case that we shall find this lesion after death ;
but it is difficult for any pathological observer not to be led to
suspect the existence of a disease in the repetition of the same
circumstances under which he has seen it occur previously.”

The diagnosis of this condition is not only possible but often
free from difficulty, at least where the disease is confirmed. On
the other hand, minor degrees of the affection are to be determi-
ned less by direct signs than by some general characters.

GENERAL DIAGNOSIS OF THE DISEASE.

321

The diagnosis turns upon three points: —

1. The existence of physical signs and symptoms of diminished
force of the heart.

2. The occurrence of certain symptoms, principally referrible
to the brain, which indicate either anannia on the arterial, or con-
gestion on the venous side, of the cerebral circulation.

3. Symptoms referrible to the respiratory function, which ap-
pear to arise from deficient power in the right ventricle.

It is still to be determined how far we can distinguish during
life the cases of weakened and dilated hearts, such as have been
already described, from those of fatty degeneration. Microscopi-
cal anatomy shows that in many of the former class there is more
or less of the adipose deposit. And it is plain that to the practi-
cal physician there is a relation between the diseases; for similar
exciting causes concur in their production, and in both the effect
of the disease is traceable to the same vital condition, namely,
debility of the heart.

In its higher degrees of development this affection is most
fi equently met with in persons who have passed the prime of
life; but minor shades of it occur in young patients, especially
where there is a complication with other visceral diseases, as, for
example, pulmonary tubercle. On the other hand, some of the
most remarkable instances are found in very old and long bed-
udden subjects; and it is observed that in such cases the altera-
tion is not confined to the heart, but extends also to the voluntary
muscles, and even to the skeleton, producing atrophy and fragility
of the bones, with a great deposit of oily matter in the cavities and
cancelli of the osseous tissue0. Though varying and apparently
opposite, its exciting causes are generally reducible to those which
would induce a depraved hsematosis. The over-fed and luxurious,
on the one hand, and the victim of want, on the other, are liable
to the disease.

Although complication with various local diseases, or with a
special morbid state such as gout, is not uncommon, yet judging
from the good state of the general health, and the absence of let
sion in the digestive, respiratory, and nervous systems after death,

a Of this condition numerous specimens may be seen in the Museum of the Richmond
Hospital.

VOL. I. v

322

fatty degeneration of the heart.

we must admit tliat the fatty heart may he, in a large number of
cases, practically considered as a local affection.

It is probable that in these uncomplicated examples, the disease
attains its greatest development, and exhibits the most characteris-
tic symptoms.

The symptoms may he divided into those referrible to the ner-
vous, respiratory, and circulating systems.

Of the nervous symptoms, the most important are the attacks
of apoplexy, or pseudo-apoplexy, to which these patients are so
liable. This affection differs from ordinary sanguineous apoplexy
in three particulars, namely, the frequent repetition of the seizures,
the rarity of consequent paralysis, and the fact that there is not
only danger from an antiphlogistic treatment, but benefit, both
remedial and preventive, from the use of stimulants.

In some cases the character of these attacks approaches to that
of syncope; and it is difficult to say how much of the affection
is produced by the want of arterial, or the stasis of venous blood.
In the earlier periods of the case the attack is more of syncope,
in the later it becomes apoplectic. The attacks may occur with-
out warning, and the first seizure he fatal. This, however, is rare.
In most cases there are numerous seizures at irregular intervals ;
and in some, sensations referrible to the epigastrium and hea ,
having a resemblance to the epileptic aura, give notice to the
patient that he is about to be attacked. In some there is a mo-
mentary unsteadiness in walking, and in others a tendency to faint,
which maybe dissipated by any ordinary stimulus; while m the
more decided cases the patient becomes suddenly comatose, a con-
dition which may be preceded by loss of memory and a lethargic
state. I have at present under my care a patient whose earlier
attacks were syncopal ; they are now apoplectic, and come on dur-
ing sleep, each one being preceded by a slight convulsion. On
recovery, and after all the comatose symptoms have passed away,
he remains for lialf-an-hour or an hour unable to recognise his
most intimate friends and relations, even his wife he has mistaken
for his mother. This patient is 63 years of age. This latter symp-
tom has been observed in a case of weak heart which lately occur-
red in Dublin ; the patient frequently failing to recognise friends
who had been his intimates for half a century. The duration of

GENERAL DIAGNOSIS OE THE DISEASE. 323

the attack is generally short, paralysis is rare, and when it occurs
does not seem referrible to any anatomical lesion of the brain.

The question as to whether these singular attacks are depen-
dent upon deficient arterial supply, or rather upon venous conges-
tion, is a difficult one, but it does not involve any important point
of practice. It is true, that whatever arrests the action of the
heart will retard the flow of blood in the veins of the head, but
it could not cause a state of hypersemia. The opinion that the
apoplectic seizures are owing to deficient arterial supply seems
the most tenable. The suddenness of the attack, and, in many in-
stances, the rapidity of the recovery, are in favour of this view.
I have noticed one case in which, on the occurrence of the pre-
monitory symptoms, the patient, by hanging his head so that it
rested on the floor, used to save himself from an attack. A case
lately occurred to me of an aneurism of the aorta, in which three
successive ruptures of the sac took place, with intervals of seve-
ral days. Each rush of blood was attended with the best-marked
syncopal coma and convulsions. Finally, dissection does not show
any extraordinary congestion of the brain; and we learn from aus-
cultation that the action of the heart is feeble.

This view of the cause of the attacks appears to be still fur-
ther corroborated by the occurrence of symptoms of a similar na-
ture in the case of dilated mitral opening by Dr. Fleming, which
has been already given. Here the ventricle was hypertrophied to
a great degree, but the patient suffered from regurgitation into the
left auricle4-

We can, therefore, only adopt in part the plan of treatment
suggested by the late Mr. Carmichael, which was to relieve the
vessels of the head by venesection, while at the same time sti-
mulants should be used to excite the action of the left ventricle.

Symptoms refernble to the respiratory function. — There is no
evidence that the existence of this disease, even in an aggravated
form, is an exciting cause of any organic affection of the lung.
On the other hand, the researches of Ormerod, Quain, and others,
have demonstrated the frequent combination of fatty heart with
pulmonary disease ; but in such cases we may hold that the con-

a See Case xxm. page 206.
Y 2

324

FATTY DEGENERATION OF THE HEART.

ditions of the lung and heart have little, if any, mutual relation ;
they are rather to be considered as the secondary accidents of a
general morbid state.

But there is a symptom which appears to belong to a weakened
state of the heart, and which, therefore, may be looked for in many
cases of the fatty degeneration. I have never seen it except in
examples of that disease. The symptom in question was observed
by Dr. Cheyne, although he did not connect it with the special
lesion of the heart8. It consists in the occurrence of a series of
inspirations, increasing to a maximum, and then declining in
force and length, until a state of apparent apncea is established.
In this condition the patient may remain for such a length ol time
as to make his attendants believe that he is dead, when a low in-
spiration, followed by one more decided, marks the commencement
of a new ascending and then descending series of inspirations. This
symptom, as occurring in its highest degree, I have only seen
during a few weeks previous to the death of the patient. I do
not know any more remarkable or characteristic phenomena than
those presented in this condition, whether we view the long-con-
tinued cessation of breathing, yet without any suffering on the part
of the patient, or the maximum point of the senes of inspirations,
when the head is thrown back, the shoulders raised, and every
muscle of inspiration thrown into the most violent action ; yet all
this without rale or any sign of mechanical obstruction. The ve-
sicular murmur becomes gradually louder, and at the height of

the paroxysm is intensely puerile.

The decline in the length and force of the respirations, is as
regular and remarkable as their progressive increase. The inspi-
rations become each one less deep than the preceding, until they
are all but imperceptible, and then the state of apparent, apncea
occurs. This is at last broken by the faintest possible inspiration ;
the next effort is a little stronger, until, so to speak, the paroxysm
of breathing is at its height, again to subside by a descending

SCCllc*

In other cases we see the symptom of sighing to occur in a
different manner: at irregular intervals the patient draws a sin-

* See page 303.

GENERAL DIAGNOSIS OF THE DISEASE.

325

gle deep sigh, especially when he suffers from fatigue, want of
food, or of his ordinary stimulants. This is the commonest form
of the affection11. In one case it was always most evident when
the patient was lying down.

The phenomena of circulation are next to be considered.

We are in want of a sufficient number of observations to ena-
ble us to declare whether in the earlier periods there is any marked
character of pulse as to strength, frequency, or regularity. Many
of the recorded cases of the minor stages of the disease are defi-
cient in accurate observations of the pulse ; but it may be held
that no special character of pulse has been established. In some
the pulse has been weak, rapid, and irregular; in others it does

“ The sighing respiration maybe observed in persons who are labouring under certain
forms of gastric or hepatic derangement, and is occasionally a symptom of undeveloped
gout It disappears under appropriate treatment, and probably indicates a temporary
weakness of the heart. I lately saw a case of long-continued sighing, in which it had ap-
parently arisen from depression and anxiety of mind, but had, as it were, become a habit.
The patient was a lady of very nervous disposition. A feeble murmur attended the first
sound of the heart. In this case there was probably no organic lesion, for the symptom
had long existed, and there were no signs of progressive disease.

Sufficient attention has not as yet been directed to this character of respiration. It is,
when confirmed, almost pathognomonic of a weak and, in all probability, a fatty heart ;
but whether it is to be taken as indicative of the predominance of the fatty change on the
right side of the heart is still an open question. Laennec has described a form of asthma
with puerile respiration, and he attributes the disease and the signs to some special modi-
fication of the nervous influence. He observes, that he has never met with it except in
persons affected with mucous catarrh, and holds that dyspnoea, arising from the mere in-
crease of the natural want of the system for respiration, can never amount to asthma
without the catarrhal complication. But he further speaks of adults and old persons who
have puerile respiration without catarrh, and who, though they are not, properly speaking,
asthmatic, are short-breathed, and liable to dyspnoea on the slightest exercise.

It is possible that in some of these cases at least, the heart may be in an incipent stage
of fatty degeneration. I have observed the symptom in a gentleman of about 70 years
of age, who has many symptoms of a weak heart. The action of that organ is regular,
but the impulse is extremely feeble, and the pulse compressible. The sounds, especially
the first, are very indistinct; there is no bronchial rale, but well-marked puerility of re-
spiration exists over every portion of the thorax. He principally complains of dyspnoea
on exercise, or on any mental agitation ; and the symptoms have only become prominent
within the last eighteen months. So far as the permanent condition of the respiration is
concerned, this case answers perfectly to Laeunec’s description of dyspnoea with puerile
respiration. See Dr. Forbes’s translation of the work of Laennec, — Article, Asthma with
Puerile Respiration.

326

FATTY DEGENERATION OF THE HEART.

not seem to have differed materially from that of health®. But in
confirmed cases we may meet with three important characters of
pulse : —

1. The pulse somewhat accelerated, but occasionally inter-
mitting ; its strength may be but little altered.

2. The extremely weak, rapid, irregular, and tingling pulse
( pulsus formicans ) .

3. The permanently slow pulse, the rate of which varies from
50 to 30 in the minute, or even less.

It is probable, that in the third class of cases, or those with
a permanently slow, though distinct and regular pulse, the dis-
ease has either advanced to a great degree, or has at all events
affected the different portions of the heart equably ; and that we
may attribute the weak and irregular pulse to conditions of the
heart in which only certain portions of the organ have degene-
rated, or where there is a great difference between the right and
left sides of the organ. It is further probable that the heait may
be in two very different conditions previous to the commence-
ment of the fatty change ; and that in the case with irregular pulse,
a merely weakened and perhaps dilated condition has preceded
the deposit of fat globules in the muscular fibre ; while in the
third class the change has occurred without previous alteration
in the structure or mode of action of the heart. Some of the cases
observed in persons who have been long bedridden, and who have
died from rupture of the left ventricle, are of this description.
Additional observations, however, are necessary to elucidate this

subject. ....

If we inquire whether irregularity of pulse is indicative of

valvular disease in this affection, we must consider that the symp-
tom may be met with in cases of weak, dilated hearts,, without
valvular disease, and, therefore, that we might expect it in the
fatty degeneration. On the other hand, the. occurrence of cases
with a perfectly regular though slow pulse is a remarkable fact.
In well-marked cases, where irregularity, rapidity, and smallness

a This circumstance is worthy of consideration in connexion with that which I have
recorded as occurring in cases of the softening of the heart in typhus, m many of which
the pulse is quite a fallacious guide in determining the strength of the left ventricle.

GENERAL DIAGNOSIS OF THE DISEASE.

327

of pulse exist, we ought not, even though there he no valvular
murmur, to declare too strongly against the existence of valvular
obstruction ; bearing in mind, first, that the very weakness of the
heart may prevent the appearance of murmur; and next, that
valvular disease is a not infrequent combination with fatty heart.
In most of the cases which I have seen, this valvular affection
was at the aortic orifice, and the pulse was slow and regular. The
following case exemplifies the disease with a contracted mitral
orifice.

Case XXXIV. — Fatly degeneration of the Heart; Contraction of

the mitral opening; Valvular Murmur loudest at the Apex; Fee-
bleness, irregularity, and rapidity of Pulse.

A man, aged 50, who had gone through a long period of suf-
fering and want, was admitted into the Meath Hospital in a state
of great debility. His pulse was small, rapid, feeble, and irregu-
lar, no two successive beats having the same character; some-
times it was short and momentary, then more distinct and, as it
were, longer ; while at others it had the creeping, tingling charac-
ter (pulsus formicans) . He was liable to sudden feelings of ap-
proaching death, attended with temporary loss of recollection, and
was affected with frequent and deep sighing, especially when in
the recumbent posture. The lungs showed signs of chronic bron-
chitis, and the liver appeared engorged. On each attack of the
pulmonary dyspnoea the liver became augmented in volume. The
impulse was very feeble, and a valvular murmur existed loudest
at the apex and over the left side of the heart.

On dissection, the heart was found generally enlarged, and
covered with a thick layer of fat, lying between the muscular
structure and pericardium, and in many places dipping down
through the fibres. It was most abundant at the base and the up-
per and

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